Malignancy risk of gastric ulcers: could it be higher than the expected values?

There are many reported methods in the literature for the discrimination between malignant and benign gastric ulcers by endoscopic evaluation, but unfortunately this could not be done in 20% of the cases. The sensitivity for diagnosis of malignant ulcers increases by multiple biopsies and endoscopies. In this study, solitary gastric ulcers which were detected at 1680 gastroscopies between January 2001 and June 2002 are evaluated. The ulcers which were on gastric mass, multiple little aphthous ulcers and ulcers with hemorrhagic erosions having a diameter less than 0.5 cm are excluded from the study. There were a total of 32 patients, 20 males and 10 females, having a median age of 54.8 years. In the initial biopsy, only nine patients had malignancy results. The 23 cases having benign results had medical treatment with proton pump inhibitors for four weeks. At the end of this period, they had their second gastroscopic evaluation. The ulcers of 14 patients did not heal and second round biopsies were per formed. Additionally four cases had malignant results following the second round biopsy. After 4 weeks the remaining 10 cases had their third round of gastroscopy which revealed that two patients still had the ulcer. A third round biopsy was done and one case had a malignancy result. A total of 14 malignancy cases was encountered, and nine of them was adenocarcinoma, four were signet cell carcinoma and one case was MALT lymphoma. 78% of the malignant cases were encountered at the proximal site of the incisura angularis, and in 64% of these malignant cases nodular lesions around the ulcer were encountered. The four ulcers out of eight which were settled at the smaller curvature site were malignant, and only one ulcer at cardia was also malignant. The main method for the discrimination of malign-benign ulcer is still biopsy. The follow up of the patients with repeated multiple biopsies may increase the sensitivity for diagnosis of malignancies in the solitary gastric ulcer.