Experience of gastric cancer screening in Japan: This blood test index may be very important.
Dr. Guan Kang Kang You from the Department of Nuclear Medicine talks about thyroid gland.
1. What is pepsinogen?
Pepsinogen (PG) is the precursor of pepsin. According to its biochemical properties and immunogenicity, it can be divided into two subgroups. The immunogenicity of 1~5 components is the same, and it is called Pepsinogen I (PG I), which is mainly secreted by the main cells of gastric fundus gland and mucus neck cells. Components 6 and 7 are called pepsinogen Ⅱ(PGⅡ), which can be secreted by the main cells and mucus neck cells of gastric fundus gland, and also produced by mucus neck cells of pyloric gland of cardiac gland and gastric antrum and upper duodenum.

Usually, about 1% PG enters the blood circulation through the capillary of gastric mucosa, and the PG entering the blood circulation is very stable in the blood. Serum PG ⅰ and PG ⅱ reflect the number of glands and cells in gastric mucosa, and indirectly reflect the secretory function of different parts of gastric mucosa. When pathological changes occur in gastric mucosa, the content of serum PG also changes. Therefore, monitoring the concentration of PG in serum can be used as a means to monitor the status of gastric mucosa.
Detection of pepsinogen (PG), an early warning indicator of gastric cancer
1. Chronic atrophic gastritis is an important "transitional event" in gastric mucosa canceration.
Gastric cancer is one of the common malignant tumors in China, and its mortality ranks first among all kinds of malignant tumors. Its early diagnosis and early treatment have become the only way to improve the quality of life of patients and reduce the mortality. At present, the main methods for diagnosing gastric cancer are fiberoptic gastroscopy and upper gastrointestinal radiography, among which gastroscopy is called the "gold standard" for diagnosing gastric cancer.

At present, it is believed that partial atrophy can be reversed, and once it enters intestinal metaplasia, it is difficult to reverse it. Therefore, there is an urgent need for a tool that can keenly detect the atrophy of gastric mucosa. At this time, the detection of pepsinogen plays a powerful role.
When the gastric fundus gland atrophied, the number of main cells decreased and the level of PG ⅰ decreased. However, because there are more cells secreting PG ⅱ, PG ⅱ can still maintain a high level at this time, and the ratio of PG ⅰ to PG ⅱ decreased significantly. When atrophic gastritis is accompanied by intestinal metaplasia and gastric antrum gland extends to the stomach body, and pseudopyloric metaplasia of gastric fundus gland occurs, the level of PG ⅱ increases more, and the ratio of PG ⅰ to PG ⅱ decreases further. Therefore, the decrease of PG ⅰ level is a reliable sign of gastric fundus gland mucosa atrophy, and PG ⅰ/PG ⅱ profile reflects the degree of gastric fundus gland mucosa atrophy.

2. Helicobacter pylori infection is the initiating factor for the development of gastric cancer.
The occurrence of gastric cancer is the result of multiple factors. The multi-step hypothesis of gastric cancer, that is, from chronic non-atrophic gastritis (formerly known as chronic superficial gastritis) → atrophic gastritis → intestinal metaplasia → intraepithelial neoplasia (formerly known as dysplasia) → gastric cancer, has been generally accepted. Helicobacter pylori (Hp) infection has become the most important initiating factor, and Hp infection has been recognized as an independent risk factor for gastric cancer.

Therefore, active detection of Hp has become one of the important measures to prevent and treat gastric cancer. Hp detection is mainly divided into invasive and non-invasive methods. For Hp-positive infected people, the major guidelines have reached a consensus that Hp infection-related gastritis is an infectious disease and it is recommended to eradicate it.
Hp infection can also significantly affect the serum PG level. At the beginning, PG ⅰ and PG ⅱ both increased, and the increase of PG ⅱ was faster, then PG ⅰ/PG ⅱ decreased, and the larger the Hp infection focus, the greater the decrease of PG ⅰ/PG ⅱ. However, the results of pepsinogen test are lack of specificity, and special Hp test is still needed to judge whether Hp is infected or not.
Third, pepsinogen Ⅰ(PGⅠ),
The results of pepsinogen Ⅱ(PGⅡ) were analyzed as follows:

Four, "pepsinogen" test results misunderstanding:
Myth # 1: If only PG ⅰ is measured during physical examination, nearly 70% of the results are in the range of 40~70ng/mL, which seems to be lower than 70ng/mL on the surface, and gastric atrophy is suspected, but the results are difficult to explain because PG ⅱ and ratio are not measured. When PGⅡ is retested, the ratio of more than 90% is greater than 3. This kind of situation is due to the high incidence of chronic superficial gastritis in China population, which belongs to normal physiological gastric acid secretion insufficiency.
Myth 2: PG-positive means "stomach cancer theory": positive means people at high risk of stomach cancer. PG project is a simple screening project for gastric cancer in the early stage of physical examination, replacing X-ray and ultrasonic screening for gastric cancer. The main significance lies not in diagnosis but in early detection and prevention. Normal people are 15%PG positive, and those with PG positive have a high risk of developing gastric cancer, and the early detection rate of gastric cancer is 1%~2%.
Myth # 3: Pay attention to the change of reference range values of PG ⅰ and PG ⅱ, but not the ratio. Because the secretion of PG ⅰ in gastric mucosa changes greatly (above 70~800ng/mL) under the attack of inflammation, the secretion of PG ⅱ is relatively constant. When comparative value > 3, the degree of PG ⅰ increase can only be combined with clinical analysis to determine the type of gastric diseases. When comparative value < 3, it is suggested that further in-depth endoscopy or pathological sampling should be taken to confirm and warn the high risk of early gastric cancer, and follow-up monitoring should be carried out in the last five years. The incidence of gastric cancer was 2% in PG-positive patients who had no gastric cancer in the same year and in the following five years.
Five, Japan’s experience for reference ("ABC" method+endoscopic screening)
Our neighbor Japan, as a country with high incidence of gastric cancer, has done a very good job in early cancer screening. Their screening strategy for early cancer firmly grasps the two controllable factors of Hp infection and whether gastric fundus gland atrophy occurs.

The Kyoto Consensus of Japan made the following recommendations for the national early cancer screening strategy: first, for Hp infection, the Kyoto Consensus emphasized "shoot to kill", and after everyone sterilized and eradicated Hp, PG was evaluated. The ratio of PG ⅰ/PG ⅱ is ≤3.0, which is regarded as the critical diagnostic value of atrophic gastritis, and as the screening standard of high-risk population of gastric cancer.

Vi. A Long Way to Go-Strategies for Early Cancer Screening in China;
China has a large population base and the incidence of gastric cancer remains high, so it is imperative to find a simple, accurate and effective screening method for gastric cancer. In 2017, the China Consensus on Chronic Gastritis highly affirmed the value of PG, and the guidelines gave the following recommendations: The detection of serum pepsinogen (PG) ⅰ and ⅱ and gastrin -17 may help to judge whether there is gastric mucosal atrophy and its degree. Detection of serum PG ⅰ, PG ⅱ, PG ⅰ/PG ⅱ ratio combined with anti-Hp antibody is helpful for risk stratification management.
The Expert Consensus on Early Gastric Cancer Screening Process in China, published at the end of 2017, not only affirmed the value of serum PG, but also put forward a new gastric cancer screening scoring system, in which the elderly, male, Hp antibody positive, low pepsinogen ratio (PGR) and high serum 17(gastrin-17 (G-17) level are high risk factors for gastric cancer.

Among them, G-17 is a new item in China Guide. G-17 is an amidated gastrin synthesized and secreted by G cells in gastric antrum. Its main physiological function is to stimulate gastric acid secretion and promote the proliferation and differentiation of gastric mucosal cells. G-17 is one of the sensitive indexes to reflect the endocrine function of gastric antrum, which can indicate the atrophy of gastric antrum mucosa or whether there is abnormal proliferation. G-17 itself can also promote the occurrence and development of gastric cancer. When the serum G-17 level rises, it may indicate the risk of gastric cancer.

In addition, different from the Kyoto consensus, the consensus in China put forward the critical value of serological detection for the first time, that is, when PGR<3.89 and G-17> 1.50pmol/L, the risk of gastric cancer increased significantly. The critical value of PGR defined by Kyoto Consensus is ≤3.
According to the score, the guide divides the population into three groups: low risk, medium risk and high risk, and gives the screening strategy.

At the same time, however, we should also see the shortcomings of the China guidelines. The screening population is over 40 years old, and there are other risk factors such as high incidence area of gastric cancer, Hp infection, previous precancerous diseases of gastric cancer, first-degree relatives of gastric cancer patients, diet and so on. However, at present, the onset age of gastric cancer is getting earlier and earlier, and I believe it will definitely enter prospecting stage in the future.
To sum up, serum PG combined with Hp detection is helpful to evaluate the risk of gastric cancer, and can be used as a routine screening method for gastric cancer for ordinary people. However, it cannot replace gastroscopy, and gastroscopy is still strongly recommended for high-risk groups.

Original title: Clinical Significance of Detection of Pepsinogen (PG)
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