Preneoplastic conditions in the stomach: always a point of no return?

Gastric atrophy (GA) and intestinal metaplasia are defined preneoplastic conditions of the stomach, whereas Helicobacter pylori gastritis by itself represents a risk condition for gastric cancer (GC) development. After H. pylori eradication, an overall reduction of GC incidence has been shown. However, this effect is lost once H. pylori gastritis has evolved to severe GA. On the other hand, only up to 5% of patients with severe GA may develop intestinal-type GC, and therefore the so-called 'point of no return' may not be appropriate to define the condition of all patients carrying preneoplastic changes in the gastric mucosa. Patients with the highest risk for GC are those who have already had GC that was cured by endoscopic resection. Prospective trials on the effect of H. pylori eradication in this high-risk group of patients showed inconsistent results, probably because of the inclusion of patients with and without baseline severe GA. Severe fundic GA determined by means of histology or serology represents the condition with the highest risk for metachronous neoplastic lesions in the stomach. In the present review, we focus on the effects of H. pylori eradication in patients with severe atrophy in terms of GC prevention.