White globe appearance is an endoscopic predictive factor for synchronous multiple gastric cancer

Authors Teppei Masunaga, Naohiro Yoshida, Shinichiro Akiyama, Gen Sugiyama, Hirokazu Hirai, Saori Miyajima, Shigenori Wakita, Yosuke Kito, Hiroyoshi Nakanishi, Kunihiro Tsuji, Kazuhiro Matsunaga, Shigetsugu Tsuji, Kenichi Takemura, Kazuyoshi Katayanagi, Hiroshi Minato, Hisashi Doyama.


Background White globe appearance (WGA) is a small white lesion with a globular shape identified during magnifying endoscopy with narrow-band imaging. However, the association between WGA and synchronous multiple gastric cancer (SMGC) remains unclear.

Methods Consecutive patients who underwent endoscopic submucosal dissection for gastric cancer (GC) between July 2013 and April 2015 at our institution were eligible for this study. We excluded patients with a history of gastric tumor or gastrectomy. Patients who had more than 2 GCs in their postoperative pathological evaluation were classified as SMGC-positive, and patients who had at least 1 WGA-positive GC were classified as WGA-positive patients. The primary outcome was a comparison of the prevalence of WGA in patients classified as SMGC positive and SMGC-negative. Univariate and multivariate analyses were performed using the following variables: WGA, age, sex, atrophy, and Helicobacter pylori (H. pylori) status.

Results There were 26 and 181 patients classified as SMGC-positive and SMGC-negative, respectively. Univariate analysis revealed that WGA-positive classification (50% vs. 23%, P=0.008) and male sex (88% vs. 66%, P=0.02) were significant factors associated with SMGC classification, while age ≥65 years (81% vs. 81%, P>0.99), severe atrophy (46% vs. 46%, P>0.99), and H. pylori positivity (69% vs. 65%, P=0.8) were not. In the multivariate analysis, only WGA-positive classification (odds ratio 2.78, 95% confidence interval 1.16-6.67; P=0.02) was a significant independent risk factor for SMGC.

Conclusions Our exploratory study showed the possibility of WGA as a predictive factor for SMGC. In cases of WGA-positive gastric cancer, careful examination might be needed to diagnose SMGC.

Keywords White globe appearance, gastric cancer, endoscopic submucosal dissection, synchronous multiple gastric cancer

Ann Gastroenterol 2021; 34 (2): 183-187

Original Articles