Research ArticleDifferent Incidence of Early-Onset Gastric CarcinomaDepending on Ethnicity Preliminary Results of aHospital in Liangshan

Shen Li1 Peter Rexin2 Zhang Qin3 Chen Changbo4 Chen Guanghui1 Wang Luyao1

Hans-Ullrich Voelker 5 and Gerhard Stauch6

1Department of Pathology No 1 Hospital Liangshan Xichang China2Department of Pathology Aurich Westerstede Westerstede Germany3Department of Gastroenterology No 1 Hospital Liangshan Xichang China4Department of Foreign Affairs No 1 Hospital Liangshan Xichang China5Pathology Leopoldina Hospital Schweinfurt Schweinfurt Germany6Senior Expert Service Bonn Bonn Germany

Correspondence should be addressed to Hans-Ullrich Voelker hvoelkerleopoldinade

Received 17 November 2019 Accepted 20 February 2020 Published 10 March 2020

Academic Editor Gianandrea Pasquinelli

Copyright copy 2020 Shen Li et alis is an open access article distributed under the Creative Commons Attribution License whichpermits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Background In China the incidence of cancer has significantly decreased over the last two decades In contrast the incidence ofgastric carcinoma (GC) has risen in young patients Methods We reevaluated the histopathological results of 4353 endoscopicgastroscopies from the Department of Pathology at No 1Hospital of Liangshane ethnic groups Han and Yi were almost equallydistributed in this cohort Over a five-year period 1407 GC were diagnosed Results In 171 of these cases (12) the patients werele40 years old (early-onset GC EOGC) Out of this cohort 9 patients were aged le25 years 54 of these patients were male andshowed marked predominance (92) of the Yi-minority Using the classification of Lauren 103 GC (60) were of diffuse type 27(16) of intestinal type and 41 (24) of mixed type In the remaining 1236 cases of patients ge41 years (88) 1014 patients (82)belonged to the Yi-minority Helicobacter pylori (HP) were found in 46 of all cases Familial clustering was found in 14 patients(18 in first degree relatives 12 and in second degree relatives 6) Follow-up was not possible Conclusion is studydemonstrates the unequal manifestation of EOGC within the two ethnic groups of Han and Yi However familial clustering wasinfrequent Further investigations are necessary to discover relevant risk factors apart from hereditary predisposition

1 Introduction

Gastric carcinoma (GC) is the fourth most common type ofcancer with a high rate of cancer-related deaths despitemanifold therapeutical efforts [1] In China its incidence hassignificantly decreased over the last two decades mostly inurban and to some extent in rural areas However an in-creasing number of cases can be found in young patientsunder 40 years [2 3] which is classified as early-onset GC(EOGC)

Over the last five decades the histological classificationof GC has been largely based on Laurenrsquos criteria [4] with

discrimination of the intestinal- diffuse- and indeterminatemixed-type e literature describes the incidences of ap-proximately 50 for the intestinal- 35 for the diffuse- and15 for the mixed-type Laurenrsquos classification is currentlyaccepted worldwide as a simple and robust approach for thedetermination of histological subtypes which exhibit anumber of distinct clinical characteristics including epide-miology aetiology tumorigenesis cell differentiation bio-logical behavior and prognosis [5ndash7]

GC research is hampered by the diversity of factorswhich can induce tumor growth ese include numerousexogenous and environmental factors such as bacterial

Hindawie Scientific World JournalVolume 2020 Article ID 6845413 5 pageshttpsdoiorg10115520206845413

infections with Helicobacter pylori (HP) variations of life-style and diet [8ndash14] as well as genetic or epigenetic ab-normalities which affect tumor suppressor genes andmismatch repair genes [15] In this way clinical research isfaced with a seemingly unsolvable puzzle It is generallyassumed that GC in young patients is more often induced bygenetic and epigenetic alterations in contrast to the pre-dominance of environmental factors in older patients

In 2017 the author GS noticed in own unpublishedobservations a high incidence of EOGC within the histo-logically verified cases of GC in the Department of Pathologyof No 1 Hospital of Liangshan in Xichang Based on thisimpression we carried out a pilot study to examine thedistribution of patients with regard to the ethnic groups Hanand Yi Furthermore we investigated the degree of infectionby HP and the familial risk of the affected patients

2 Materials and Methods

Between April 2013 and April 2018 the Department ofPathology of No 1 Hospital investigated the biopsy speci-mens from 4353 endoscopic gastroscopies histologically Inthis cohort the distribution to ethnicity of patients to Hanand Yi was analyzed this assignment to ethnic groups wasalso made for cases of GC All patients were residents ofLiangshan prefecture New slides of every block of paraffin-embedded tumor specimens were manufactured and stainedwith hematoxylin-eosin (HampE) Giemsa and periodic acid-Schiff-diastase (PAS-D) e gastric carcinomas were his-tologically reevaluated and classified in terms of Lauren andthe recent WHO classification by the authors SL and GS inJuneJuly 2018

e patients in the EOGC group of le40 years weresubgrouped as follows le20 21ndash25 26ndash30 31ndash35 and 36ndash40years e patients in the GC group of ge41 years weresubgrouped as follows 41ndash50 51ndash60 and ge61 years

e rate of HP infection for each group and tumor typewas evaluated histologically using the Giemsa stain by twoexperienced pathologists

In the 77 patients of the EOGC group le40 years thedocumentation of an individual and familial case history waspossible by phone interview and by tracing hospitaldocuments

3 Results

e distribution of ethnic groups Han and Yi the ages ofpatients and the histological results of endoscopy from 4353cases are shown in Figure 1 2143 (492) biopsy specimenswere from the Han-majority and 2210 specimens (508)from the Yi-minority so that a sampling bias could beexcluded

In 1407 cases (323) the biopsy specimens from gas-troscopy contained GC 171 of these tumor specimens (12)originated from patients le40 years so that an EOGC wasdiagnosed Table 1 shows the distribution of age tumor typeand ethnic group e prevalence of the Yi-population inEOGC was 94 and in the cohort of patients ge41 years was

88 (1088 cases)emost striking result was that 9 patientsfrom 14ndash25 years with EOGC showed 100 Yi ethnicity

In 77 of 171 patients with EOGC (44) it was possible toanalyze the oncologic history of close relatives 14 patients ofYi-minority showed tumors in 9 first-degree relatives and 5second-degree relatives All tumors of these 14 patients wereof diffuse- or mixed-type according to Lauren (Table 2) eexamination of exogenous and environmental factors as faras possible in anamnesis showed no difference in thequantity of alcohol and nicotine consumption between Han-and Yi-population However the traditional diet differsbetween Han and Yi with the latter preferring more saltedsmoked meat and fermented vegetables

4 Discussion

e available information about gastric carcinoma (GC) iscomplicated by a host of partially interdependent aetio-logical factors of exogenous and genetic nature Exogenousfactors can comprise bacterial environmental and dietaryfactors as well as lifestyle and exposure to toxic substancesey differ in the potency of malignant transformationExogenous factors are modulated by the immunological andgenetic background of the host and differing genetic pen-etration which may cause gene activation or suppression Inaddition to sporadic carcinomas there are 3ndash5 purelyhereditary carcinomas defined by autosomal dominantmutations e frequency of tumor patients of lt25 years inthis group strongly supports this theory Guiford et al al-ready revealed in 1986 the genetic background in youngpatients [11 12] A familial clustering such as in the Yi-families was already found in studies of someMaori-familiesin New Zealand Other results of different study groupsrevealed a genetic GC disposition in juvenile patients withLindashFraumeni syndrome Lynch syndrome PeutzndashJegherssyndrome juvenile polyposis syndrome or Cowden syn-drome [14]

e Yi-population is a minority of more than 6 millionpeople mostly living in Sichuan and Yunnan with a rela-tively homogeneous genetic background mostly because ofthe traditional separation from the surrounding Han-ma-jority by social rules different language different religionand their remote living situation in mountainous and in-accessible areas Familial clustering may be a strong sign ofgenetic influence but additional exogenous factors such ashygiene and traditional food habits with consumption ofsalted and smoked red meat and fermented fish and picklescannot be excluded [16 17] With increasing assimilationbetween ethnicities the influence of genetic similarity willdecrease

emost important exogenous factor in GC induction isan infection with Helicobacter pylori (HP) which is con-trolled by the oncogenicity of HP CagA Epuiya-c and msiVacA types as well as the genetic susceptibility of hosts [18]is is mainly true for sporadic carcinoma Carcinoma candevelop in the setting of long-term exposure to HP via acascade of morphological changes In cases of EOGC tumorinduction has however also been associated with a highincidence of HP In almost all studies up to 80 of GC

2 e Scientific World Journal

patients are infected with HP (see Table 3) [16 17 19] In ourstudy HP was found in less than 46 ese results may beblurred by preferential sampling of specimens directly fromthe neoplastic area Biochemical control measurements werenot performed in this study Especially newer studies ofEOGC have shown an increased incidence of HP infectionwhich suggests this as a cofactor for malignant transfor-mation To what extent early and consistent eradication ofHP in children can contribute to minimizing GC incidencein these risk groups must be evaluated by furtherinvestigations

A stage classification of the GC was not possible in ourcohort as comprehensive data concerning pretherapeuticstaging (computer tomography) were not available andrespectively only 33 patients (19) underwent furthertherapeutical procedures Both overall survival and disease-free survival could not be determined in this study De-tection methods of CDH1 germline mutations were also notfeasible in the time frame of the study

e high percentage of patients of the Yi-minority bothin the EOGC group and in the GC group lt40 years has not

Table 1 Early-onset gastric carcinomas in the 1407 reevaluated samples of all included gastric carcinomas

Age nGender Lauren type

Yi-minorityMale Female Diffuse Intestinal Mixed

le20 4 3 (75) 1 (25) 4 (100) mdash mdash 4 (100)21ndash25 5 4 (80) 1 (20) 4 (80) mdash 1 (20) 5 (100)26ndash30 21 14 (67) 7 (33) 14 (67) 4 (19) 3 (14) 19 (90)31ndash35 43 26 (60) 17 (40) 29 (67) 6 (14) 8 (19) 42 (98)36ndash40 98 53 (54) 45 (46) 52 (53) 17 (17) 29 (30) 88 (90)1113936 171 100 (59) 71 (41) 103 (60) 27 (16) 41 (24) 158 (92)

900

800

700

600

500

400

300

200

100

0

n

lt20 21ndash25 26ndash30 31ndash35 36ndash40 41ndash50 51ndash60Age

gt61

GC (Yi)GC (Han)

Figure 1 Number of endoscopic evaluation of stomach by taking biopsies for histological investigations in patients of Yi and Han ethnicity

Table 2 Gastric carcinoma (GC) in grade 1 and grade 2 relatives of77 interviewed patients

Gender Age Cancertype

Relative grade1 Relative grade 2

M 24 D GC MoF 25 D GC Fa +GC SiF 26 D GC Un

F 40 Mi Tumor notclassifiable

F 38 D GC SibM 38 D GC SibF 37 Mi GC UnF 38 D GC 3X UnF 40 D GC MoM 40 D GC Mo

F 37 D GC Sib +GCFa

M 39 Mi GC UnM 40 Mi GC SibM 39 D GC FaM-male F-female D-diffuse type of Lauren Mi-mixed type of Lauren Fa-father Mo-mother Si-sister and Un-uncle

e Scientific World Journal 3

been described up to now However individual families withgastric carcinoma clustering were identified by Guiford et alin New Zealand as well as by other groups in Italy Only Baiand Li have described a significant tumor clustering in aChinese study [19] Susceptibility of individual ethnic groupsseems to play a decisive role for the oncogenic potency ofsome HP strains in particular the Cag andmsi VacA groupsin which malignant transformation into intestinal carci-noma types is frequently expected [15]

In the cohort presented here the authors could not findsignificant differences in lifestyle and alcohol or nicotineconsumption in contrast to Lee et al [18] However weobserved different eating habits in the Yi-population with apreference for smoked and salted meat and fermentedvegetables whose carcinogenicity was particularly high-lighted by Japanese study groups [20] e dietary differ-ences are however of increasingly minor importancebecause the Yi have been assimilated more and more to theHan lifestyle in the last decades

5 Conclusion

Our study gives a first insight into differences in the de-velopment of early-onset gastric cancer in different ethnicgroups with a distinctly higher incidence of this disease inthe Yi-population Apart from lifestyle parameters diet andfrequency of Helicobacter pylori infections further studiesare necessary to reveal the genetic background of thisphenomenon with the aim to identify families or individualswith a higher risk for gastric cancer so that these could beincluded in programs for early detection

Data Availability

All data are given in the study Material is archived followingthe rules of Hospital No 1 Liangshan

Ethical Approval

For this retrospective analysis all data were completelyanonymized according to the Declaration of Helsinki estudy was approved by the Ethics Committee of the No 1Hospital of Liangshan (NO2019001)

Consent

All patients have given consent in writing to this studywithin the framework of a treatment contract with the No 1

Hospital Separate written consent was given for the ano-nymized data to be evaluated with regard to the patientsrsquoindividual and family medical history In conjunction withtheir general written consent for participation in this study(see above) all patients submitted their explicit writtenconsent for the publication of selected personal or clinicaldetails All data were completely anonymized after evalua-tion (only sex and age were documented and not initialsnames or other individual data) Patients were informedabout the lack of traceability of individual data

Conflicts of Interest

e authors declare no conflicts of interest with respect tothe research authorship andor publication of this article

Authorsrsquo Contributions

SL GS and PR designed the study LS ZQ CC CG andWLwere involved in data collection and analysis and HUV PRand GS in interpretation GS drafted the manuscript Allauthors critically reviewed the manuscript and approved thefinal version All authors take responsibility for the integrityor the accuracy of any part of the work

Acknowledgments

e authors gratefully thankMr Cao Lisheng Director of thehospital and Mrs Fan Suna assistant of director for thegenerous support to the study and Mr Chen Hao for hisenormous technical help of the team compliance withclinical standards

References

[1] R Sitarz M Skierucha J Mielko J OfferhausR Maciejewski and W Polkowski ldquoGastric cancer epide-miology prevention classification and treatmentrdquo CancerManagement and Research vol Volume 10 pp 239ndash2482018

[2] J Yin J N Song and Z G Bai ldquoGastric cancer mortalitytrends in China 2006ndash2013 reveal an increasing mortality inyoung subjectsrdquo Anticancer Research vol 37 no 8pp 4671ndash4675 2017

[3] X Zhu and J Li ldquoGastric carcinoma in China current stateand future perspectivesrdquo Oncology Letters vol 1 no 3pp 407ndash412 2010

[4] P Lauren ldquoe two histological main types of gastric car-cinoma diffuse and so-called intestinal-type carcinomardquoActa

Table 3 Literature review from three studies compared with the own study

Author Bay et al [19] China Kono et al [16] Japan Quach et al [17] Vietnam Own studyStudy design Prospective Retrospective Prospective RetrospectiveNumber of cases 250 72 141 171Age median 31 35 35 37Gender malefemale ratio 066 11 1109 11Diffuse type of Lauren 64 92 87 88Helicobacter pylori Not reported 81 73 46Clinical stage Not reported III-IV III-IV Not reportedFamilial history 19 10 0 12

4 e Scientific World Journal

Pathologica Microbiologica Scandinavica vol 64 no 1pp 31ndash49 1965

[5] M-Z Qiu M-Y Cai D-S Zhang et al ldquoClinicopathologicalcharacteristics and prognostic analysis of Lauren classificationin gastric adenocarcinoma in Chinardquo Journal of TranslationalMedicine vol 11 no 1 p 58 2013

[6] Y-C ChenW-L Fang R-F Wang et al ldquoClinicopathologicalvariation of lauren classification in gastric cancerrdquo Pathology ampOncology Research vol 22 no 1 pp 197ndash202 2016

[7] B Hu N El Hajj S Sittler N Lammert R Barnes andA Meloni-Ehrig ldquoGastric cancer classification histology andapplication of molecular pathologyrdquo Journal of Gastrointes-tinal Oncology vol 3 no 3 pp 251ndash261 2012

[8] J H Siman A Forsgren G Berglund and C-H FlorenldquoTobacco smoking increases the risk for gastric adenocarci-noma among Helicobacter pylori-infected individualsrdquoScandinavian Journal of Gastroenterology vol 36 no 2pp 208ndash213 2001

[9] J Parsonnet D Vandersteen J Goates R K SibleyJ Pritikin and Y Chang ldquoHelicobacter pylori infection inintestinal-and diffuse-type gastric adenocarcinomasrdquo JNCIJournal of the National Cancer Institute vol 83 no 9pp 640ndash643 1991

[10] H Brenner V Arndt G Bode C Stegmaier H Ziegler andT Stumer ldquoRisk of gastric cancer among smokers infectedwith Helicobacter pylorirdquo International Journal of Cancervol 98 no 3 pp 446ndash449 2002

[11] P Guiford J Hopkins J Harraway et al ldquoE-cadherin germline mutation in familial gastric cancerrdquo Nature vol 392pp 402ndash405 1998

[12] P Guilford B Humar and V Blair ldquoHereditary diffusegastric cancer translation of CDH1 germline mutations intoclinical practicerdquo Gastric Cancer vol 13 no 1 pp 1ndash10 2010

[13] E-M Wolf J B Geigl M Svrcek M Vieth and C LangnerldquoHereditares magenkarzinomrdquo Der Pathologe vol 31 no 6pp 423ndash429 2010

[14] R S Van Der Post I P Vogelaar F Carneiro et al ldquoHe-reditary diffuse gastric cancer updated clinical guidelines withan emphasis on germline CDH1mutation carriersrdquo Journal ofMedical Genetics vol 52 no 6 pp 361ndash374 2015

[15] J Bacani R Zwingerman and N Di Nicolo ldquoTumormicrosatellite instability in early onset gastric cancerrdquo 7eJournal of Molecular Diagnostics vol 7 no 4 pp 465ndash4772005

[16] Y Kono H Kanzaki T Tsuzuki et al ldquoA multicenter ob-servational study on the clinicopathological features of gastriccancer in young patientsrdquo Journal of Gastroenterology vol 54no 5 pp 419ndash426 2019

[17] D T Quach D V Ha and T Hiyama ldquoe endoscopic andclinico pathological characteristics of early onset gastriccancer in Vietnamese patientsrdquo Asian Pacific Journal ofCancer Prevention vol 19 no 7 pp 1883ndash1886 2018

[18] S-A Lee D Kang K Shim J Choe W Hong and H ChoildquoEffect of diet and helicobacter pylori infection to the risk ofearly gastric cancerrdquo Journal of Epidemiology vol 13 no 3pp 162ndash168 2003

[19] Y Bai and Z-S Li ldquoEndoscopic clinicopathological featuresand prognosis of very young patients with gastric cancerrdquoJournal of Gastroenterology and Hepatology vol 26 no 11pp 1626ndash1629 2011

[20] K Shikata Y Kiyohara M Kubo et al ldquoA prospective studyof dietary salt intake and gastric cancer incidence in a definedJapanese population the Hisayama studyrdquo InternationalJournal of Cancer vol 119 no 1 pp 196ndash201 2006

e Scientific World Journal 5

patients are infected with HP (see Table 3) [16 17 19] In ourstudy HP was found in less than 46 ese results may beblurred by preferential sampling of specimens directly fromthe neoplastic area Biochemical control measurements werenot performed in this study Especially newer studies ofEOGC have shown an increased incidence of HP infectionwhich suggests this as a cofactor for malignant transfor-mation To what extent early and consistent eradication ofHP in children can contribute to minimizing GC incidencein these risk groups must be evaluated by furtherinvestigations

A stage classification of the GC was not possible in ourcohort as comprehensive data concerning pretherapeuticstaging (computer tomography) were not available andrespectively only 33 patients (19) underwent furthertherapeutical procedures Both overall survival and disease-free survival could not be determined in this study De-tection methods of CDH1 germline mutations were also notfeasible in the time frame of the study

e high percentage of patients of the Yi-minority bothin the EOGC group and in the GC group lt40 years has not

Table 1 Early-onset gastric carcinomas in the 1407 reevaluated samples of all included gastric carcinomas

Age nGender Lauren type

Yi-minorityMale Female Diffuse Intestinal Mixed

le20 4 3 (75) 1 (25) 4 (100) mdash mdash 4 (100)21ndash25 5 4 (80) 1 (20) 4 (80) mdash 1 (20) 5 (100)26ndash30 21 14 (67) 7 (33) 14 (67) 4 (19) 3 (14) 19 (90)31ndash35 43 26 (60) 17 (40) 29 (67) 6 (14) 8 (19) 42 (98)36ndash40 98 53 (54) 45 (46) 52 (53) 17 (17) 29 (30) 88 (90)1113936 171 100 (59) 71 (41) 103 (60) 27 (16) 41 (24) 158 (92)

900

800

700

600

500

400

300

200

100

0

n

lt20 21ndash25 26ndash30 31ndash35 36ndash40 41ndash50 51ndash60Age

gt61

GC (Yi)GC (Han)

Figure 1 Number of endoscopic evaluation of stomach by taking biopsies for histological investigations in patients of Yi and Han ethnicity

Table 2 Gastric carcinoma (GC) in grade 1 and grade 2 relatives of77 interviewed patients

Gender Age Cancertype

Relative grade1 Relative grade 2

M 24 D GC MoF 25 D GC Fa +GC SiF 26 D GC Un

F 40 Mi Tumor notclassifiable

F 38 D GC SibM 38 D GC SibF 37 Mi GC UnF 38 D GC 3X UnF 40 D GC MoM 40 D GC Mo

F 37 D GC Sib +GCFa

M 39 Mi GC UnM 40 Mi GC SibM 39 D GC FaM-male F-female D-diffuse type of Lauren Mi-mixed type of Lauren Fa-father Mo-mother Si-sister and Un-uncle

e Scientific World Journal 3

been described up to now However individual families withgastric carcinoma clustering were identified by Guiford et alin New Zealand as well as by other groups in Italy Only Baiand Li have described a significant tumor clustering in aChinese study [19] Susceptibility of individual ethnic groupsseems to play a decisive role for the oncogenic potency ofsome HP strains in particular the Cag andmsi VacA groupsin which malignant transformation into intestinal carci-noma types is frequently expected [15]

In the cohort presented here the authors could not findsignificant differences in lifestyle and alcohol or nicotineconsumption in contrast to Lee et al [18] However weobserved different eating habits in the Yi-population with apreference for smoked and salted meat and fermentedvegetables whose carcinogenicity was particularly high-lighted by Japanese study groups [20] e dietary differ-ences are however of increasingly minor importancebecause the Yi have been assimilated more and more to theHan lifestyle in the last decades

5 Conclusion

Our study gives a first insight into differences in the de-velopment of early-onset gastric cancer in different ethnicgroups with a distinctly higher incidence of this disease inthe Yi-population Apart from lifestyle parameters diet andfrequency of Helicobacter pylori infections further studiesare necessary to reveal the genetic background of thisphenomenon with the aim to identify families or individualswith a higher risk for gastric cancer so that these could beincluded in programs for early detection

Data Availability

All data are given in the study Material is archived followingthe rules of Hospital No 1 Liangshan

Ethical Approval

For this retrospective analysis all data were completelyanonymized according to the Declaration of Helsinki estudy was approved by the Ethics Committee of the No 1Hospital of Liangshan (NO2019001)

Consent

All patients have given consent in writing to this studywithin the framework of a treatment contract with the No 1

Hospital Separate written consent was given for the ano-nymized data to be evaluated with regard to the patientsrsquoindividual and family medical history In conjunction withtheir general written consent for participation in this study(see above) all patients submitted their explicit writtenconsent for the publication of selected personal or clinicaldetails All data were completely anonymized after evalua-tion (only sex and age were documented and not initialsnames or other individual data) Patients were informedabout the lack of traceability of individual data

Conflicts of Interest

e authors declare no conflicts of interest with respect tothe research authorship andor publication of this article

Authorsrsquo Contributions

SL GS and PR designed the study LS ZQ CC CG andWLwere involved in data collection and analysis and HUV PRand GS in interpretation GS drafted the manuscript Allauthors critically reviewed the manuscript and approved thefinal version All authors take responsibility for the integrityor the accuracy of any part of the work

Acknowledgments

e authors gratefully thankMr Cao Lisheng Director of thehospital and Mrs Fan Suna assistant of director for thegenerous support to the study and Mr Chen Hao for hisenormous technical help of the team compliance withclinical standards

References

[1] R Sitarz M Skierucha J Mielko J OfferhausR Maciejewski and W Polkowski ldquoGastric cancer epide-miology prevention classification and treatmentrdquo CancerManagement and Research vol Volume 10 pp 239ndash2482018

[2] J Yin J N Song and Z G Bai ldquoGastric cancer mortalitytrends in China 2006ndash2013 reveal an increasing mortality inyoung subjectsrdquo Anticancer Research vol 37 no 8pp 4671ndash4675 2017

[3] X Zhu and J Li ldquoGastric carcinoma in China current stateand future perspectivesrdquo Oncology Letters vol 1 no 3pp 407ndash412 2010

[4] P Lauren ldquoe two histological main types of gastric car-cinoma diffuse and so-called intestinal-type carcinomardquoActa

Table 3 Literature review from three studies compared with the own study

Author Bay et al [19] China Kono et al [16] Japan Quach et al [17] Vietnam Own studyStudy design Prospective Retrospective Prospective RetrospectiveNumber of cases 250 72 141 171Age median 31 35 35 37Gender malefemale ratio 066 11 1109 11Diffuse type of Lauren 64 92 87 88Helicobacter pylori Not reported 81 73 46Clinical stage Not reported III-IV III-IV Not reportedFamilial history 19 10 0 12

4 e Scientific World Journal

Pathologica Microbiologica Scandinavica vol 64 no 1pp 31ndash49 1965

[5] M-Z Qiu M-Y Cai D-S Zhang et al ldquoClinicopathologicalcharacteristics and prognostic analysis of Lauren classificationin gastric adenocarcinoma in Chinardquo Journal of TranslationalMedicine vol 11 no 1 p 58 2013

[6] Y-C ChenW-L Fang R-F Wang et al ldquoClinicopathologicalvariation of lauren classification in gastric cancerrdquo Pathology ampOncology Research vol 22 no 1 pp 197ndash202 2016

[7] B Hu N El Hajj S Sittler N Lammert R Barnes andA Meloni-Ehrig ldquoGastric cancer classification histology andapplication of molecular pathologyrdquo Journal of Gastrointes-tinal Oncology vol 3 no 3 pp 251ndash261 2012

[8] J H Siman A Forsgren G Berglund and C-H FlorenldquoTobacco smoking increases the risk for gastric adenocarci-noma among Helicobacter pylori-infected individualsrdquoScandinavian Journal of Gastroenterology vol 36 no 2pp 208ndash213 2001

[9] J Parsonnet D Vandersteen J Goates R K SibleyJ Pritikin and Y Chang ldquoHelicobacter pylori infection inintestinal-and diffuse-type gastric adenocarcinomasrdquo JNCIJournal of the National Cancer Institute vol 83 no 9pp 640ndash643 1991

[10] H Brenner V Arndt G Bode C Stegmaier H Ziegler andT Stumer ldquoRisk of gastric cancer among smokers infectedwith Helicobacter pylorirdquo International Journal of Cancervol 98 no 3 pp 446ndash449 2002

[11] P Guiford J Hopkins J Harraway et al ldquoE-cadherin germline mutation in familial gastric cancerrdquo Nature vol 392pp 402ndash405 1998

[12] P Guilford B Humar and V Blair ldquoHereditary diffusegastric cancer translation of CDH1 germline mutations intoclinical practicerdquo Gastric Cancer vol 13 no 1 pp 1ndash10 2010

[13] E-M Wolf J B Geigl M Svrcek M Vieth and C LangnerldquoHereditares magenkarzinomrdquo Der Pathologe vol 31 no 6pp 423ndash429 2010

[14] R S Van Der Post I P Vogelaar F Carneiro et al ldquoHe-reditary diffuse gastric cancer updated clinical guidelines withan emphasis on germline CDH1mutation carriersrdquo Journal ofMedical Genetics vol 52 no 6 pp 361ndash374 2015

[15] J Bacani R Zwingerman and N Di Nicolo ldquoTumormicrosatellite instability in early onset gastric cancerrdquo 7eJournal of Molecular Diagnostics vol 7 no 4 pp 465ndash4772005

[16] Y Kono H Kanzaki T Tsuzuki et al ldquoA multicenter ob-servational study on the clinicopathological features of gastriccancer in young patientsrdquo Journal of Gastroenterology vol 54no 5 pp 419ndash426 2019

[17] D T Quach D V Ha and T Hiyama ldquoe endoscopic andclinico pathological characteristics of early onset gastriccancer in Vietnamese patientsrdquo Asian Pacific Journal ofCancer Prevention vol 19 no 7 pp 1883ndash1886 2018

[18] S-A Lee D Kang K Shim J Choe W Hong and H ChoildquoEffect of diet and helicobacter pylori infection to the risk ofearly gastric cancerrdquo Journal of Epidemiology vol 13 no 3pp 162ndash168 2003

[19] Y Bai and Z-S Li ldquoEndoscopic clinicopathological featuresand prognosis of very young patients with gastric cancerrdquoJournal of Gastroenterology and Hepatology vol 26 no 11pp 1626ndash1629 2011

[20] K Shikata Y Kiyohara M Kubo et al ldquoA prospective studyof dietary salt intake and gastric cancer incidence in a definedJapanese population the Hisayama studyrdquo InternationalJournal of Cancer vol 119 no 1 pp 196ndash201 2006

e Scientific World Journal 5

been described up to now However individual families withgastric carcinoma clustering were identified by Guiford et alin New Zealand as well as by other groups in Italy Only Baiand Li have described a significant tumor clustering in aChinese study [19] Susceptibility of individual ethnic groupsseems to play a decisive role for the oncogenic potency ofsome HP strains in particular the Cag andmsi VacA groupsin which malignant transformation into intestinal carci-noma types is frequently expected [15]

In the cohort presented here the authors could not findsignificant differences in lifestyle and alcohol or nicotineconsumption in contrast to Lee et al [18] However weobserved different eating habits in the Yi-population with apreference for smoked and salted meat and fermentedvegetables whose carcinogenicity was particularly high-lighted by Japanese study groups [20] e dietary differ-ences are however of increasingly minor importancebecause the Yi have been assimilated more and more to theHan lifestyle in the last decades

5 Conclusion

Our study gives a first insight into differences in the de-velopment of early-onset gastric cancer in different ethnicgroups with a distinctly higher incidence of this disease inthe Yi-population Apart from lifestyle parameters diet andfrequency of Helicobacter pylori infections further studiesare necessary to reveal the genetic background of thisphenomenon with the aim to identify families or individualswith a higher risk for gastric cancer so that these could beincluded in programs for early detection

Data Availability

All data are given in the study Material is archived followingthe rules of Hospital No 1 Liangshan

Ethical Approval

For this retrospective analysis all data were completelyanonymized according to the Declaration of Helsinki estudy was approved by the Ethics Committee of the No 1Hospital of Liangshan (NO2019001)

Consent

All patients have given consent in writing to this studywithin the framework of a treatment contract with the No 1

Hospital Separate written consent was given for the ano-nymized data to be evaluated with regard to the patientsrsquoindividual and family medical history In conjunction withtheir general written consent for participation in this study(see above) all patients submitted their explicit writtenconsent for the publication of selected personal or clinicaldetails All data were completely anonymized after evalua-tion (only sex and age were documented and not initialsnames or other individual data) Patients were informedabout the lack of traceability of individual data

Conflicts of Interest

e authors declare no conflicts of interest with respect tothe research authorship andor publication of this article

Authorsrsquo Contributions

SL GS and PR designed the study LS ZQ CC CG andWLwere involved in data collection and analysis and HUV PRand GS in interpretation GS drafted the manuscript Allauthors critically reviewed the manuscript and approved thefinal version All authors take responsibility for the integrityor the accuracy of any part of the work

Acknowledgments

e authors gratefully thankMr Cao Lisheng Director of thehospital and Mrs Fan Suna assistant of director for thegenerous support to the study and Mr Chen Hao for hisenormous technical help of the team compliance withclinical standards

References

[1] R Sitarz M Skierucha J Mielko J OfferhausR Maciejewski and W Polkowski ldquoGastric cancer epide-miology prevention classification and treatmentrdquo CancerManagement and Research vol Volume 10 pp 239ndash2482018

[2] J Yin J N Song and Z G Bai ldquoGastric cancer mortalitytrends in China 2006ndash2013 reveal an increasing mortality inyoung subjectsrdquo Anticancer Research vol 37 no 8pp 4671ndash4675 2017

[3] X Zhu and J Li ldquoGastric carcinoma in China current stateand future perspectivesrdquo Oncology Letters vol 1 no 3pp 407ndash412 2010

[4] P Lauren ldquoe two histological main types of gastric car-cinoma diffuse and so-called intestinal-type carcinomardquoActa

Table 3 Literature review from three studies compared with the own study

Author Bay et al [19] China Kono et al [16] Japan Quach et al [17] Vietnam Own studyStudy design Prospective Retrospective Prospective RetrospectiveNumber of cases 250 72 141 171Age median 31 35 35 37Gender malefemale ratio 066 11 1109 11Diffuse type of Lauren 64 92 87 88Helicobacter pylori Not reported 81 73 46Clinical stage Not reported III-IV III-IV Not reportedFamilial history 19 10 0 12

4 e Scientific World Journal

Pathologica Microbiologica Scandinavica vol 64 no 1pp 31ndash49 1965

[5] M-Z Qiu M-Y Cai D-S Zhang et al ldquoClinicopathologicalcharacteristics and prognostic analysis of Lauren classificationin gastric adenocarcinoma in Chinardquo Journal of TranslationalMedicine vol 11 no 1 p 58 2013

[6] Y-C ChenW-L Fang R-F Wang et al ldquoClinicopathologicalvariation of lauren classification in gastric cancerrdquo Pathology ampOncology Research vol 22 no 1 pp 197ndash202 2016

[7] B Hu N El Hajj S Sittler N Lammert R Barnes andA Meloni-Ehrig ldquoGastric cancer classification histology andapplication of molecular pathologyrdquo Journal of Gastrointes-tinal Oncology vol 3 no 3 pp 251ndash261 2012

[8] J H Siman A Forsgren G Berglund and C-H FlorenldquoTobacco smoking increases the risk for gastric adenocarci-noma among Helicobacter pylori-infected individualsrdquoScandinavian Journal of Gastroenterology vol 36 no 2pp 208ndash213 2001

[9] J Parsonnet D Vandersteen J Goates R K SibleyJ Pritikin and Y Chang ldquoHelicobacter pylori infection inintestinal-and diffuse-type gastric adenocarcinomasrdquo JNCIJournal of the National Cancer Institute vol 83 no 9pp 640ndash643 1991

[10] H Brenner V Arndt G Bode C Stegmaier H Ziegler andT Stumer ldquoRisk of gastric cancer among smokers infectedwith Helicobacter pylorirdquo International Journal of Cancervol 98 no 3 pp 446ndash449 2002

[11] P Guiford J Hopkins J Harraway et al ldquoE-cadherin germline mutation in familial gastric cancerrdquo Nature vol 392pp 402ndash405 1998

[12] P Guilford B Humar and V Blair ldquoHereditary diffusegastric cancer translation of CDH1 germline mutations intoclinical practicerdquo Gastric Cancer vol 13 no 1 pp 1ndash10 2010

[13] E-M Wolf J B Geigl M Svrcek M Vieth and C LangnerldquoHereditares magenkarzinomrdquo Der Pathologe vol 31 no 6pp 423ndash429 2010

[14] R S Van Der Post I P Vogelaar F Carneiro et al ldquoHe-reditary diffuse gastric cancer updated clinical guidelines withan emphasis on germline CDH1mutation carriersrdquo Journal ofMedical Genetics vol 52 no 6 pp 361ndash374 2015

[15] J Bacani R Zwingerman and N Di Nicolo ldquoTumormicrosatellite instability in early onset gastric cancerrdquo 7eJournal of Molecular Diagnostics vol 7 no 4 pp 465ndash4772005

[16] Y Kono H Kanzaki T Tsuzuki et al ldquoA multicenter ob-servational study on the clinicopathological features of gastriccancer in young patientsrdquo Journal of Gastroenterology vol 54no 5 pp 419ndash426 2019

[17] D T Quach D V Ha and T Hiyama ldquoe endoscopic andclinico pathological characteristics of early onset gastriccancer in Vietnamese patientsrdquo Asian Pacific Journal ofCancer Prevention vol 19 no 7 pp 1883ndash1886 2018

[18] S-A Lee D Kang K Shim J Choe W Hong and H ChoildquoEffect of diet and helicobacter pylori infection to the risk ofearly gastric cancerrdquo Journal of Epidemiology vol 13 no 3pp 162ndash168 2003

[19] Y Bai and Z-S Li ldquoEndoscopic clinicopathological featuresand prognosis of very young patients with gastric cancerrdquoJournal of Gastroenterology and Hepatology vol 26 no 11pp 1626ndash1629 2011

[20] K Shikata Y Kiyohara M Kubo et al ldquoA prospective studyof dietary salt intake and gastric cancer incidence in a definedJapanese population the Hisayama studyrdquo InternationalJournal of Cancer vol 119 no 1 pp 196ndash201 2006

e Scientific World Journal 5

Pathologica Microbiologica Scandinavica vol 64 no 1pp 31ndash49 1965

[5] M-Z Qiu M-Y Cai D-S Zhang et al ldquoClinicopathologicalcharacteristics and prognostic analysis of Lauren classificationin gastric adenocarcinoma in Chinardquo Journal of TranslationalMedicine vol 11 no 1 p 58 2013

[6] Y-C ChenW-L Fang R-F Wang et al ldquoClinicopathologicalvariation of lauren classification in gastric cancerrdquo Pathology ampOncology Research vol 22 no 1 pp 197ndash202 2016

[7] B Hu N El Hajj S Sittler N Lammert R Barnes andA Meloni-Ehrig ldquoGastric cancer classification histology andapplication of molecular pathologyrdquo Journal of Gastrointes-tinal Oncology vol 3 no 3 pp 251ndash261 2012

[8] J H Siman A Forsgren G Berglund and C-H FlorenldquoTobacco smoking increases the risk for gastric adenocarci-noma among Helicobacter pylori-infected individualsrdquoScandinavian Journal of Gastroenterology vol 36 no 2pp 208ndash213 2001

[9] J Parsonnet D Vandersteen J Goates R K SibleyJ Pritikin and Y Chang ldquoHelicobacter pylori infection inintestinal-and diffuse-type gastric adenocarcinomasrdquo JNCIJournal of the National Cancer Institute vol 83 no 9pp 640ndash643 1991

[10] H Brenner V Arndt G Bode C Stegmaier H Ziegler andT Stumer ldquoRisk of gastric cancer among smokers infectedwith Helicobacter pylorirdquo International Journal of Cancervol 98 no 3 pp 446ndash449 2002

[11] P Guiford J Hopkins J Harraway et al ldquoE-cadherin germline mutation in familial gastric cancerrdquo Nature vol 392pp 402ndash405 1998

[12] P Guilford B Humar and V Blair ldquoHereditary diffusegastric cancer translation of CDH1 germline mutations intoclinical practicerdquo Gastric Cancer vol 13 no 1 pp 1ndash10 2010

[13] E-M Wolf J B Geigl M Svrcek M Vieth and C LangnerldquoHereditares magenkarzinomrdquo Der Pathologe vol 31 no 6pp 423ndash429 2010

[14] R S Van Der Post I P Vogelaar F Carneiro et al ldquoHe-reditary diffuse gastric cancer updated clinical guidelines withan emphasis on germline CDH1mutation carriersrdquo Journal ofMedical Genetics vol 52 no 6 pp 361ndash374 2015

[15] J Bacani R Zwingerman and N Di Nicolo ldquoTumormicrosatellite instability in early onset gastric cancerrdquo 7eJournal of Molecular Diagnostics vol 7 no 4 pp 465ndash4772005

[16] Y Kono H Kanzaki T Tsuzuki et al ldquoA multicenter ob-servational study on the clinicopathological features of gastriccancer in young patientsrdquo Journal of Gastroenterology vol 54no 5 pp 419ndash426 2019

[17] D T Quach D V Ha and T Hiyama ldquoe endoscopic andclinico pathological characteristics of early onset gastriccancer in Vietnamese patientsrdquo Asian Pacific Journal ofCancer Prevention vol 19 no 7 pp 1883ndash1886 2018

[18] S-A Lee D Kang K Shim J Choe W Hong and H ChoildquoEffect of diet and helicobacter pylori infection to the risk ofearly gastric cancerrdquo Journal of Epidemiology vol 13 no 3pp 162ndash168 2003

[19] Y Bai and Z-S Li ldquoEndoscopic clinicopathological featuresand prognosis of very young patients with gastric cancerrdquoJournal of Gastroenterology and Hepatology vol 26 no 11pp 1626ndash1629 2011

[20] K Shikata Y Kiyohara M Kubo et al ldquoA prospective studyof dietary salt intake and gastric cancer incidence in a definedJapanese population the Hisayama studyrdquo InternationalJournal of Cancer vol 119 no 1 pp 196ndash201 2006

e Scientific World Journal 5