00:00:00: Hello, everyone. Welcome to this episode of the USU Talks.

00:00:03: It's Pradeepundra here, and I'm your host for today.

00:00:07: This is the second part of our podcast on MAPS,

00:00:11: three guidelines with Professor Mario Denis Ribeiro,

00:00:16: full professor of the Faculty of Medicine at the University of Porto,

00:00:20: consultant gastroenterologist and head of

00:00:23: Porto Comprehensive Cancer Centre and

00:00:27: vice-director of the research centre there.

00:00:30: If you haven't listened to the first part of this episode, I urge you to do so

00:00:34: before listening to this. This is the second part of the two-part

00:00:38: series. So in the first part we discussed

00:00:42: the scope of the MAPS three guidelines. We discussed screening for gastric

00:00:48: cancer and pre-malignant lesions. We also discussed

00:00:52: population-based screening and how to become

00:00:55: better in recognising and describing pre-malignant lesions

00:01:01: in that episode. So let's continue that in this second part.

00:01:05: Here to come. Mario, coming on to the next statement or the other

00:01:10: statements that come through, you made a statement on use of AI-assisted

00:01:14: detection. Now, I have covered this in one of the

00:01:17: other podcasts, a use of AI in the upper G.I. track with Alana

00:01:21: Hebicbeau. That's a much longer one. We discussed all aspects, but what was the

00:01:25: guideline committee recommendation on use of artificial intelligence

00:01:30: in the upper G.I. track as of now? I'm sure this is an evolving field

00:01:35: and things will change in the future. So first of all, we had the chance to

00:01:39: systemically review the literature a couple of years ago and what we've

00:01:44: shown was that most of the systems reached the expert level

00:01:48: defined as the chance of not missing more than 10 percent. And I think

00:01:52: this is a scary feature or number that was

00:01:56: consistently suggested that we may miss 10 percent of lesions seen

00:02:01: in the stomach. And based on this, AI was kind of

00:02:05: levelled to this level. And for detection,

00:02:08: ESG recommended that the system should have 90 percent of detection

00:02:13: rate or above. For characterization, we could accept

00:02:18: a lower threshold of 80 percent again, as experts are able to

00:02:22: anticipate curative resection for when they see

00:02:25: superficial lesions, and the same 90 percent for detecting

00:02:29: premalignant conditions. So this threshold is, well, we can compare

00:02:33: this with other metrics that we have in other parts of the globe

00:02:37: for the use of virtual commandoscopy, etc. But for instance,

00:02:41: are these levels of accuracy that eventually providers

00:02:46: of AI, are we there? The studies, they say yes, but then, for instance, when we

00:02:51: go for cost-effectiveness to try to see if AI could bring

00:02:57: to a different level the performance of bestoscopy in different countries,

00:03:01: we would require a higher level of accuracy from the systems

00:03:05: at the low cost. For instance, for Netherlands and for Italy, that those

00:03:10: were the countries that we used as contrast to Portugal

00:03:14: to show if these systems could be cost-effective if they

00:03:18: would be applied to endoscopy. So answering briefly, what we said

00:03:24: is that if the systems that you may have in front of you are

00:03:28: already validated and have that threshold,

00:03:32: I think this will come to our practice. We don't want to miss a class, so when

00:03:36: we do an astroscopy, and we would like to have systems that

00:03:40: eventually automatically would stage the strategies that is in front of you, and

00:03:45: we'll say even okay, you need to survey all these patients.

00:03:48: Yeah, just for clarity, Mario, when you refer to AI detection,

00:03:54: meeting expert standards, is that detection of

00:03:58: pre-elegant lesions or is that detection of dysplasia and cancer?

00:04:02: Just want to clarify that. They are both. Yeah, both. So there are systems that are

00:04:07: more developed for detecting cancer.

00:04:11: There are some studies, not that many, for detecting pre-elegant.

00:04:16: And even in our group, we have been

00:04:19: presenting that recently, where we were able to develop some algorithms

00:04:24: that can establish as good as experts

00:04:28: the staging of intestinal manipulation. So we will be there,

00:04:32: not now, but we will be there. Yeah. Mario, I just wanted to cover a couple of

00:04:35: points from the astrodraws who routinely deal with

00:04:39: management of dysplasia and early cancer.

00:04:41: There's a couple of things I think they would benefit from discussing.

00:04:46: Let's say patients have early gastric cancer,

00:04:49: which is resectible endoscopically. The routine practice

00:04:54: in our centre is anything that's called a cancer we do

00:04:58: as staging CT scan. But the guideline committee seems to deviate

00:05:01: slightly from that. I think if you just say a couple of lines about it,

00:05:06: because that's, I think, is a bit practice changing and potentially

00:05:10: will save a lot of resources. And I remember for my days when I was in

00:05:15: Japan, they didn't do CT scans there. So we seem to

00:05:19: differ in the West. Can you just say a couple of lines for

00:05:22: the benefit of gastric doctors who deal with these things?

00:05:25: Yeah, definitely. So what we suggested was that,

00:05:29: of course, this is applicable to all the things that you do.

00:05:33: You should have a high quality endoscopy and you need to be sure that that

00:05:36: lesion that is in front of you, you adequately

00:05:40: characterized and eventually it's enough to have been the scoping

00:05:45: fixture. So if you use the location, the size,

00:05:49: the Paris classification and in the absence of any signs

00:05:53: of deep submacosal invasion, CT scan in the US does not have

00:05:59: to be making any decisions. So of course, if the patient is comfortable

00:06:03: with that, you should resect the lesion and

00:06:05: decide afterwards. Of course, we know that we miss

00:06:09: 20% of lesions that we may, let's say, so it's a 20%

00:06:16: misdiagnosis when we allocate patients to treatment. But on the other side, we do

00:06:20: know that from these, some of them will not have surgical conditions.

00:06:24: So they were treated anyhow and some of the others will have been missed by US

00:06:30: because we do know that also a misdiagnosis occurs or misstaging occurs

00:06:35: when even among the best US performers. So in the

00:06:39: absence of signs of deep submacosal invasion, chances of having the muscle

00:06:44: appropriate also involved, there is no reason to

00:06:47: perform further staging. And this change, of course, after the

00:06:50: resection where you then you need to stage properly the patient to

00:06:54: manage if they finally not curative occurs. So in this setting,

00:06:58: the guidelines does not add too much to the most recent

00:07:02: guideline that was published before this. The effort here was just to

00:07:05: comprehensively bring this discussion towards this field.

00:07:09: So no major changes the readers may expect to see

00:07:13: within the MAPS 3-3 guidelines. So from the curative resection criteria

00:07:19: compared to previous guidelines, you're keeping it

00:07:22: roughly similar. Yeah, what we did suggest, of course,

00:07:28: it's still, it will be very difficult, but again

00:07:32: coming back to your comments where we do too many endoscopies and I

00:07:36: completely agree, what we suggested is that

00:07:40: there may be some groups of patients where in the absence of further risk

00:07:44: factors for metachronous lesions, we could release them from surveillance

00:07:48: or at least to to do a less intensified

00:07:52: surveillance after the resection. So if there is some logic about what we are

00:07:56: suggesting, you will have more screened people once in a lifetime screened

00:08:01: individuals. Some of them will harbor superficial lesions

00:08:04: and most of them will survive. So we need probably to have also some

00:08:08: metrics and measures to overburden

00:08:11: survivors that will more and more come to our services.

00:08:15: So I do expect that we endoscopies in this field of cancer, we will

00:08:20: transform the surveillance in a very, let's say, less invasive form of

00:08:26: caring of patients. I will not allude non-invasive markers because they

00:08:30: don't exist, but eventually that will come also.

00:08:33: Okay, Maria, the next section of discussion, which is probably most

00:08:38: important, I want to focus on recognizing or

00:08:43: identifying pre-metachronous lesions, how to describe these things,

00:08:47: common mistakes that are made. I think this part is extremely important for

00:08:52: most endoscopies who don't routinely deal with

00:08:56: the gastric pre-metachronous lesions or deal with

00:08:59: resection of dysplastic lesions. Now let's start with a practical question.

00:09:04: Let's say you talked about opportunistic screening. Let's say

00:09:08: patient comes in with dyspepsia and I'm doing an endoscopy

00:09:12: and I roughly know what atropia is, I know

00:09:16: what interstellar metoplasia is, and I start seeing this.

00:09:19: How systematically, how do you approach in reporting this endoscopy

00:09:24: in terms of reporting this atropia in the interstellar metoplasia

00:09:28: and what's your systematic approach to its taking the biopsies? Just, you know,

00:09:33: give us a brief summary. I'm sure the listeners can go through the guidelines

00:09:36: it's well described there. So first of all, don't focus too much on

00:09:41: biopsies and consider that you are the best morphologist

00:09:45: at that moment. So clean the mucosa, insufflate this insufflate and

00:09:50: insufflate again so that you see that you are

00:09:53: sure that you didn't miss any cancer. Okay?

00:09:57: Afterwards, I always start by looking at the entrum

00:10:01: and the incisors quite carefully. This is the region where

00:10:05: Hpylori-related male plages occur more often and still in one systematic review

00:10:11: that we also published, one quarter of the missing

00:10:14: cancers are there. So if you nicely see that region and if you take

00:10:19: time, well most of the scope providers nowadays

00:10:23: they have systems of virtual chromandoscopy and you can either

00:10:27: start by white light and move to virtual chromandoscopy

00:10:30: and get back to white light back and forward. Then with that process you also

00:10:35: learn how to recognize these changes even with

00:10:38: flashlight. Then I moved upwards and do the same process.

00:10:42: Looking at the entrum and incisora and the lesser curvature you can

00:10:46: recognize trophic changes by a pale mucosa that is whitish

00:10:52: and eventually with some line that separates these two compartments

00:10:58: differently from the anatomic compartment at this densivora. So if you

00:11:01: see that line in the entrum and in incisora probably this patient has

00:11:05: a trophic changes in the entrum, it may or may not

00:11:08: have a testamentoplasia and the same goes to the corpus that

00:11:14: that is less frequent and of course I will not allow now to

00:11:18: alter in monoconstritis that it's the other way around. You can anticipate

00:11:22: these changes most often in the corpus. When we touch the bottom to

00:11:26: use virtual chromandoscopy then you may see areas that you may recognize as

00:11:30: a testamentoplasia, bluish areas, some tubulus

00:11:34: villus pattern. You may see a light blue crest that is

00:11:38: a very very nice signal that once you see it you

00:11:43: never forget it and you may measure or anticipate the

00:11:48: extension of these changes. So in terms of report what I do is

00:11:53: I say I didn't see any superficial lesion in the fundus, in the corpus,

00:11:59: in incisora and in the entrum. I recognize

00:12:03: trophic changes by endoscopy only in the entrum,

00:12:07: in the entrum incisora or affecting the entire entrum and corpus

00:12:11: and I do recognize some changes of the testamentoplasia

00:12:14: again in the entrum incisora and or in the corpus.

00:12:18: After that if I do recognize the testamentoplasia

00:12:22: I tend to target the biopsies to those areas

00:12:26: but we should always do two biopsies in the entrum in the lesser curvature

00:12:31: and the greater curvature and two in the corpus

00:12:35: and send these two pairs separately for pathologists.

00:12:39: There is a lot of discussions if we need the biopsy from incisora,

00:12:44: there is a lot of discussion if we need to send separately these jars also to

00:12:48: save the environment to pathologists but at least

00:12:51: for now for most clinicians take care of the corpus, take care of the stomach

00:12:56: separately and report separately these morphological findings

00:13:01: and send separately the biopsies to the pathologists

00:13:04: at least in the very first endoscopy. During surveillance

00:13:09: with evidence that exists you may drop the need for biopsies

00:13:12: if you don't care again to screen for it's bilory so

00:13:16: if you screen a patient when it's 50 and you

00:13:20: and you have that patient again with 62 you may wonder if you want again to

00:13:24: know if he's h-bilory infected but without the absence of superficial

00:13:28: illusions and in the absence of you and the

00:13:32: patient wishing to know for some reason infection for h-bilory

00:13:36: once you establish the phenotype surveil that patient if it is to be surveilled

00:13:42: without biopsies. So in summary Mario it's important for the endoscopists to

00:13:48: describe whether they found actually and then describe whether it's present in

00:13:52: the entrum, whether it's extending into the insidiora,

00:13:56: whether it's extending into the body and similarly recognize

00:14:00: into some place here describe the extent of it whether restricted to the

00:14:05: entrum going up to the body and subdivision they can always say it's

00:14:10: kind of in the end to open up how extensively it's extending

00:14:14: and then take biopsies and if you've left out the biopsy from the insidiora

00:14:20: previous guidelines were recommending that's no longer

00:14:24: required and you said that there's just two biopsies

00:14:28: from the entrum two biopsies from the body.

00:14:32: Now why did you leave out insidiora biopsies anymore in the new guidelines?

00:14:36: Yeah again it's not left out it became optional because

00:14:42: there are three moments in the story in the history of this

00:14:45: suggestion of assessing both compartments. The first

00:14:49: descriptions were only with two plus two biopsies

00:14:53: then the modified Sydney Houston system

00:14:57: included insidiora biopsies because that can be eventually the

00:15:01: line where most consistently changes occur and also

00:15:05: each part of it can be found but and then of course the

00:15:09: systems for staging atrophic antestameter pleasure

00:15:12: used that insidiora biopsy biopsies in the insidiora and then the maps came

00:15:17: again suggesting only two plus two so there was some confusion and recently

00:15:22: also in another consensus regained consensus that also

00:15:25: challenged everyone to read led by professor Ruga.

00:15:29: There was some consensus on dropping as mandatory

00:15:32: the biopsies in insidiora because it doesn't have the number needed

00:15:36: to biopsy it was considered to be very high to add

00:15:40: information of course for those that in clinical practice they want

00:15:43: to continue to include and send in the same jar as the entrant that's fine

00:15:48: as long as they don't separate in a different jar because then it's the

00:15:51: environment that it's affected. There was an argument that I was

00:15:56: sensitive to recently that was some suggested that for

00:16:00: for making the biopsies in insidiora you would take more time looking at insidiora.

00:16:05: Maybe that's reasonable but there is no evidence to suggest that so

00:16:08: what I said in that lecture that someone let's say posed

00:16:13: this argument was that we need more research in this field to show definitely

00:16:17: if we need or not the

00:16:21: biases or biopsies. So for those that continue to do it, they are not against the guidelines.

00:16:23: For those that don't want to do it, they want to look carefully and use endoscopic

00:16:28: staging rather than making a further biopsy, another biopsy that's fine now. Don't focus

00:16:33: too much on biopsies. That's, I think, also a nice message because it's you trust your

00:16:39: eyes, learn how to scope, learn how to recognize and the biopsies will further help. It's the

00:16:44: same process you were first and before alluding to US and CT scans for lesions that we do

00:16:50: consider that we will treat them in this case. And this is in the West because in the East,

00:16:56: for ages, they don't do biopsies to assess a traffic change. They don't test them at

00:17:02: the plage and so they trust their eyes and they stage endoscopically the stomach.

00:17:07: Yeah, that's one thing I've seen which is different. So Mario, let's say I've got the

00:17:13: endoscopy description, I've got exactly the extent and I had the histology results. There's

00:17:18: a bit of complex grid that the guideline has recommended in terms of deciding what qualifier

00:17:24: surveillance and who do not qualify for surveillance. And we can follow that. Is there a simpler way

00:17:31: to summarizing the whole thing in one golden rule? Let's say who needs to be surveyed and

00:17:38: who doesn't need to be surveyed. Yeah. So most individuals will not require surveillance.

00:17:45: So most will have what we can call almost normal changes of minor atrophic changes in the

00:17:53: entrum and some scattered spots of emplacement at the plage. So for those individuals, we

00:17:58: do not recommend surveillance with the exception of having some family history in their families.

00:18:05: Again, neither the country or ethnicity seems to affect the surveillance rate. Okay. Eventually

00:18:12: if we come back to a screening program, again, as I said before, if these individuals come

00:18:18: for the astroscopy and if he has or he belongs to a specific ethnicity, he may return to

00:18:26: the screening protocol. For a subset of patients, it varies from subgroup to country. So it

00:18:34: correlates with the risk of gastric cancer. But for some group that is estimated between

00:18:39: three and 5% to 10% in the high risk countries, we may have to surveil these patients every

00:18:46: three years. Those patients with extensive intestinal metoplasia, but don't mix up here

00:18:51: the extensive intestinal metoplasia that sometimes you see in the reports of pathologists that

00:18:56: refers to a specific site. It's again, the report of endoscopy that you've done saying,

00:19:02: "I do see trophic changes in the entron, in caesural and corpus, with a lot of changes

00:19:08: that I recognize as endoscopy, both in the entron and both in the corpus." And eventually

00:19:13: even if you don't see them, if you have reports from pathology reporting, endoscopy in both

00:19:18: compartments, you should surveil these patients. This is an easy rule for them to surveil patients.

00:19:23: Yeah, that's very nice to simplify, Mario, because often I think the endoscopy may report

00:19:29: or there's just changes in the entron. Histopathologist says, "Listen, I've seen intestinal metoplasia

00:19:33: in the body, the corpus, and you take the worst of the devil, you take what's the worst

00:19:40: grading," so to say, because the endoscopist must have missed something, or histopathologists

00:19:45: may have missed. Yeah, that's why in the guideline we also present the table or picture where

00:19:53: we correlate both concepts, because actually when you speak about false negatives or false

00:20:01: positives of this endoscopic markers, you need to consider that the multifocality of

00:20:07: these changes may lead to, let's say, someone not finding an endoscopic finding that you

00:20:12: describe just because you missed the spot where you did the biopsy or the other way around.

00:20:17: And also, pathologies are not that reliable when they assess a trophy, and that's why

00:20:23: we didn't do that step about suggesting to use only intestinal metoplasia, but there

00:20:29: is a sentence there in the text, we suggested intestinal metoplasia should be the most reliable

00:20:35: marker, and again, you eventually further select the patients only for a third set of

00:20:42: patients to be surveilled. Again, the concern is again, yes, you should do the strong scopy,

00:20:47: yes, you should do it properly, yes, you should not miss a cancer, you should use all the

00:20:52: technologies that you have in front of you to not miss anyone, but then please, please,

00:20:57: please take care only of those that merit surveillance, because there is evidence to

00:21:01: suggest that those are the ones at risk. It's again, it's not a very strong evidence, but

00:21:07: it's consistent. It's consistent to say, and it's the best marker we have. I would say

00:21:12: that what I expect is that the schedule in three years will probably be even that too

00:21:20: often or too intensive, because we saw that for the polyps in the colon, we saw that for

00:21:26: merits. So the more we learn with this, probably in a few years we will say, okay, there is

00:21:31: another marker that we should use, much better than using these trophic changes.

00:21:37: Okay, so the most important thing is endoscopic description by the endoscopist, and histopathological

00:21:42: interpretation, a good histopathologist is saying things that you combine those and come

00:21:47: up with whether the patient needs surveillance or not. Now, Mario, what are the common mistakes

00:21:52: that you come across in clinical practice in terms of assignment of surveillance? You

00:21:58: may have come across, I've got some examples, but you probably will be, you come across

00:22:01: more of these. Can you explain to us what we can learn from where we get things wrong?

00:22:09: So when we already discussed is not stopping, not stopping surveillance, I think it's something

00:22:15: that we see often because, again, we have an ageing population. Secondly, I think we

00:22:22: somehow, we continue to see patients that do have intestinal pleasure, but only mild

00:22:29: changes in the endome and those should not be surveilled. And yeah, on the other side

00:22:35: eventually, for some reason that let's say we don't, and then we observe that also in

00:22:41: other, let's say areas in other diseases, again, such as Barrett, that these two over surveilled

00:22:48: patients with extensive intestinal pleasure. So sometimes I see both sides of the coin

00:22:54: and living in Portugal, I tend to see over surveillance more than under surveillance.

00:23:00: But I can, I also anticipate that this is seen in other countries the other way around

00:23:07: saying, okay, oh, I have a patient that does not come from a specific ethnicity, does not

00:23:12: come from a specific country. Even though there is intestinal pleasure everywhere, I

00:23:18: will not surveil this patient. This is called, it may lead to a missed opportunity for prevention.

00:23:24: I can tell you where I stand within the UK. Now, I think we have a tendency to under-call,

00:23:30: we have a tendency to not diagnose patients, and we have a tendency to under-survey rather

00:23:37: than over, I think that's the way, that's the trend I tend to see locally.

00:23:41: So coming on to the next sub-discussion, can you briefly discuss about any risk factors?

00:23:48: We know the helicobacter pylori is the main risk factor in most gastric cancers or intestinal

00:23:53: type related to that. What are the other risk factors that we need to be aware of?

00:23:59: Well, again, we focused here in, again, gastric cancer related to the helicobacter pylori,

00:24:05: but of course, in the stomach, we also have the upper part that may have other factors,

00:24:11: but it's quite consistent the role of smoking. So in all the patients, in all the patients,

00:24:17: you should suggest it's not smoking, specifically in these patients. It's not, it's not the

00:24:23: infrequent that patients are very, let's say, concerned about cancer, but they do smoke.

00:24:29: And there is some evidence also suggesting an alcohol effect. Again, we are, let's say,

00:24:34: less, less intensively suggesting to moderate the consumption of alcohol. There may be a

00:24:40: role for protective factors rather than risk factors. Beyond aspirin, we could not suggest

00:24:48: any other potentially medication that could be of benefit for these patients. Even for

00:24:55: aspirin, we suggested that for those at the high risk of having cardiovascular diseases

00:25:00: that may cure inside in terms of age for this disease. So stop smoking, eradicate the pylori

00:25:08: and eventually ingest more antioxidants. So in terms of eradication of H. pylori, does

00:25:15: it have a benefit? Once patients have already developed these three million changes or even,

00:25:21: let's say, patients have already had dysplastic changes or even early gastric cancer, let's

00:25:26: say patients were found to have alkypectopylori positive, would that benefit at that stage

00:25:32: then you've gone beyond, you've gone to a stage of chronic changes. So starting from

00:25:38: the end, if you do have a patient with an early gastric cancer, you need to eradicate

00:25:44: H. pylori because it's a risk factor for having further lesions during surveillance. If, of

00:25:51: course, if you detect a patient with H. pylori with no lesions, this is the best moment to

00:25:56: eradicate H. pylori because then you, let's say, delete the risk factor or you abolish the risk

00:26:02: factor for all the cascade. And there is some discrepancy in the data about further stages

00:26:09: and the effect of H. pylori. It's quite consistent on some effect in the atrophic, when there is

00:26:14: some atrophic changes, there is some controversy when there is established indefinite plagiarism,

00:26:20: so-called point of marital. We need to revisit all this literature because most of that was

00:26:25: based on old endoscopies, random biopsies with a multifocality of these processes.

00:26:31: And there is a strong data suggesting that H. pylori, even at an old age, has an effect

00:26:37: in reducing the risk. Why do I speak with all about the old age? Because it leads also to

00:26:43: significant atrophic changes in the decimator process. So probably if you have a decimator,

00:26:49: if you have H. pylori, even though if it doesn't regress, it may hold on the process,

00:26:54: even if you don't observe it, because it may take a while to observe that long-term effect

00:27:00: of eradication. So eradicate H. pylori, of course, if you search for that, but balancing

00:27:06: with the patient in front of you. And again, it comes with the age and the effects of eradication,

00:27:10: etc. But to make it simple, you should eradicate all the time in this setting.

00:27:16: Yeah, at any stage. Okay, lovely. That's better, that's good to learn. One of the most important

00:27:22: questions that I get when I speak to patients from a patient perspective is what they see

00:27:27: and hear in media about proton pump inhibitors and risk of gastric cancer. I think I can see that

00:27:34: you made the guideline can just make some recommendation on that. Can you just clarify

00:27:39: what is the stance from the guideline committee about this and how we need to approach this

00:27:46: with our patients? So if the patient truly has an indication to take VPI, reflux disease,

00:27:52: NSA, it's with a previous history of apoptic ulcer disease. So any reason that you and the patient

00:28:01: agree that he should continue to have VPI, he should be, let's say, less concerned about that

00:28:08: in terms of risk of gastric cancer. There is also, there is some suggestion that it may increase,

00:28:12: it may lead to, of course, apocloridia and also some effect in terms of progression,

00:28:18: but that does not, let's say, that should not, in any case, and also not only for this,

00:28:23: in any case, preclude the fact that that patient will have a better quality of life if that's the

00:28:30: outcome that we pursue or prevention of recurrence and also in the routine.

00:28:35: The paradox sometimes is installed because some of these patients are deeply concerned about

00:28:40: cancer, but they do smoke, they are overweight, they have other risk factors, and they are so

00:28:46: concerned about VPI. So we need to also use this opportunity to make an holistic approach to this

00:28:52: patient and try to convince them to make primary changes that will be, let's say, more consistent

00:29:00: with a better health life than only the topic of cancer. So the bottom line is to reassure,

00:29:09: I guess, and patients that there's real good indication, continue and reassure.

00:29:14: So, Marie, I've left out the discussion on management displays here and early gastric

00:29:18: cancer from this because I think that's a very specialist field. We need another hour to discuss

00:29:23: that, so we'll leave that out. Thanks for covering all the aspects and the guidelines have been

00:29:29: written so nicely, the charts are amazing, the diagrams are really good, and I do ask the

00:29:36: listeners to read that, although it's 40 pages, it is a good read. Now, what I couldn't understand,

00:29:41: oh, I found it fascinating, is why maps, where did this come from? Thank you for the question.

00:29:46: So you challenge the readers to read, and I challenge the readers and the researchers to

00:29:52: push and also challenge the guidelines because we need more evidence to continue to suggest what

00:29:58: you suggested or to change what we suggested. So please come with good research. So the maps,

00:30:05: the maps acronym, I think it was, let's say, during a discussion as this one,

00:30:12: reading at the title that we were giving to the guideline that goes for management of patients

00:30:19: with pre-cancerous conditions in the stomach, so management and pre-cancerous and stomach,

00:30:28: the S, and it was nicely, let's say, crystallized with maps because it refers to a message that we

00:30:35: already alluded during this discussion that you should map the stomach, you should make an overview

00:30:41: of the entire mucosa, and you should take biopsies. So the maps goes for the main message of the

00:30:48: management of these patients, that you should look at the stomach as a whole and make a map.

00:30:53: You were involved in most iterations of the maps, is that correct? So how did the journey

00:31:00: start with all this? Yeah, so I dedicated most of my PhD thesis to this topic and then in 2008,

00:31:09: I was elected council for ESG and by chance, Ernst Kuipers, also very much interested in this

00:31:18: topic and also Professor Fatima Carnero, she is Portuguese and she was the president of European

00:31:23: Society of Pathology. So there was a coincidence that in the three boards, there were people

00:31:30: interested in this topic, that is, even though it's kind of, let's say, gastric cancer is considered

00:31:35: to be rare in Europe, you find gastritis and the management of these patients every day

00:31:42: in your clinical practice. Like coincidence, the fact that we have a network, this is also a nice

00:31:48: message, we were able to convince our societies that we could join forces and then for that first

00:31:55: edition, I was the first author. For the second edition, I was honored to be the last and then

00:32:02: this time I became again the first. So let's see how it goes for the next four and five years.

00:32:07: The network is very important and to change what we do. I'm glad leaders like you

00:32:16: exist who take initiative in these things and I'm very glad that you have spent the last

00:32:23: one or two hours discussing this with us today. Thanks for the EEG for everything.

00:32:28: No, thank you for inviting me and it's an honor and a pleasure always to discuss about this and

00:32:34: other topics. So see you soon. Thanks Mario. Bye bye.