Journal of Cytology
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Year : 2021  |  Volume : 38  |  Issue : 2  |  Page : 82-87
Prognostic Role of Intragastric Cytopathology and Microbiota in Surgical Patients with Stomach Cancer

1 Department of Medicine and Surgery, University of Parma, Parma; Department of General Surgery, di Vaio Hospital, Fidenza (PR), Italy
2 Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University “Sapienza”, St. Andrea Hospital, Rome, Italy
3 Department of Anesthesiology and Reanimation, St. Andrea Hospital, Rome, Italy
4 Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, University “Sapienza,” Rome, Italy
5 Department of General Surgery, di Vaio Hospital, Fidenza (PR); Department of Experimental Medicine, University of L'Aquila, L'Aquila, Italy

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Date of Submission21-Dec-2020
Date of Acceptance24-Mar-2021
Date of Web Publication11-May-2021


Background: In the last decade, analysis of malignant cells and flora in gastric lavage (GL) has provided interesting data on pathogenesis of gastric cancer (GC). For this study, combining such two aspects into one cyto-microbiologic category, we tested the prognostic role of the presence/absence of cancer cells (GL1/GL0) and bacterial microbiota (MB1/MB0) in our GC population. Material and Methods: Between April 2012 and August 2019, 79 surgical patients with GC were prospectively investigated with the determination of GL MB. Results: Compared with GL1 MB0, GL1 MB1 strongly correlated with advanced GC, portended poorer overall survival (OS) (45.8 months vs 20.5 months, P = 0.049), and resulted a significant (P = 0.008) and an independent (P = 0.013) prognostic factor unfavorable for OS. Conclusion: In the light of our results, the cyto-microbiologic parameter of GL MB should be used to gain a better prognosis of GC patients. Administration of antimicrobial treatment for MB1 subjects should be entertained because it could reduce the risk of oncogenesis.

Keywords: Fluid cytology, gastric cancer, gastric microbiota, gastrointestinal cytology, non-gynecologic cytopathology

How to cite this article:
Virgilio E, Giarnieri E, Carico E, Montagnini M, Villani S, Fiorenti M, Cavallini M, Montali F, Costi R. Prognostic Role of Intragastric Cytopathology and Microbiota in Surgical Patients with Stomach Cancer. J Cytol 2021;38:82-7

How to cite this URL:
Virgilio E, Giarnieri E, Carico E, Montagnini M, Villani S, Fiorenti M, Cavallini M, Montali F, Costi R. Prognostic Role of Intragastric Cytopathology and Microbiota in Surgical Patients with Stomach Cancer. J Cytol [serial online] 2021 [cited 2022 Dec 6];38:82-7. Available from:

   Introduction Top

Diverging from other adenocarcinomas affecting the enteral tube, gastric cancer (GC) carcinogenesis is poorly understood impeding the identification of efficient measures for early diagnosis, curative treatment, and reliable prognosis.[1],[2],[3],[4] Consequently, as of 2021, GC is still the third leading cause of cancer-related mortality in the world (783.000 deaths per year).[5],[6] Since the last decade, cytologic and molecular analysis of gastric lavage (GL) of GC patients has provided interesting results.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17] Gastric bacterial microbiota (MB) represents another original issue for GC research drawing medical attention.[18],[19],[20],[21],[22] The stomach lumen, in fact, is not sterile and physiologically hosts a rich MB (approximately 102–104 colony forming units per gram content) mainly composed of the genus Lactobacillus, Clostridium, Propionibacterium, Streptococcus, and Staphylococcus.[23] In the presence of Helicobacter pylori (H. pylori)-positive gastritis and pre-cancerous lesions, MB composition is deeply subverted with an important increase of Lactobacillus, Clostridium, and Pseudomonas and a major decrease of Streptococcus and Bacteroides.[24] Subsequently, penetrating through epithelial mucosa and activating immune system activation, these taxa could co-promote tumor transformation and growth in concert with H. pylori and other factors.[18],[25] In this study, we combined endoluminal cytology and microbiology into one examination and investigated the clinicopathologic significance and prognostic role of this mixed innovative item: the “GL MB” parameter.

   Materials and Methods Top

We prospectively analyzed the clinicopathologic data of 79 GC patients who were admitted between April 2012 and August 2019 to our Division of General Surgery. Our study followed the principles of the Declaration of Helsinki (as revised in Brazil 2013); individual informed consent was obtained from all participants before enrolment. All the participants have been followed until April 2020 or death. All the procedures of nasogastric tube insertion with subsequent GL were conducted by the same operator: in brief, under general anesthesia and before surgical act, the GL was collected under sterile conditions through a nasogastric tube and immediately transported to laboratory and cytopathology service.[15] The following cytomorphological criteria were considered pathognomonic of malignancy: nuclear changes (atypia, anisokaryosis), increased and/or abnormal mitotic figures, high nucleus-to-cytoplasm ratio, nucleolar hypertrophy or multiplicity, highly condensed nuclear chromatin, cytosolic vacuoles (signet-ring cells), pleomorphism, hypertrophy, presence of aggregates, and pseudopapillary [Figure 1].[9] Gastric microbiota (cocci, bacilli, hyphae, and spores) was microscopically evaluated on the same smears prepared for cytologic examination and stained according to the Papanicolaou method [Figure 2] [Figure 3].[26] Helicobacter pylori (H. pylori) status was further examined in those GL samples showing bacilli by our bacteriology laboratory technicians; bacterial features such as Gram-negative staining, helical or spiral shape, flagellar filaments, diameter of about 0.5 μm, and positive correlation with preoperative gastric biopsies were considered consistent with the microbiologic diagnosis of H. pylori infection. Histopathology of surgical specimens was described following the 8th ed.ition of AJCC TNM Staging System.[27] Metastatic lymph node ratio (LNR) was classified into a 4-tier system: LNR0 (0.0), LNR1 (>0–0.3), LNR2 (>0.3–0.6), and LNR3 (>0.6).[9]
Figure 1: Cluster of gastric cancer cells exfoliated into gastric lavage (Papanicolaou stain, 9100 oil immersion. Magnification: 44× field of view)

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Figure 2: Gastric lavage gastric cancer cells with numerous cocci (Papanicolaou stain, 9100 oil immersion. Magnification: 44× field of view)

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Figure 3: Malignant cells exfoliated into gastric lavage with cocci, bacilli, and neutrophils (Papanicolaou stain, 9100 oil immersion. Magnification: 44× field of view)

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Statistical analysis was performed using MedCalc Statistical Software version 19.4.1 (MedCalc Software Ltd, Ostend, Belgium). Categorical, ordinal, and continuous variables were compared using the Chi-square, Kruskal-Wallis, logistic regression, Pearson correlation coefficient, and Student's t-test. Overall survival (OS) was evaluated as the time from GL collection to death from any cause.[7],[9] Survival curves were interpreted and compared through the Kaplan-Meier method and the log-rank test. Univariate and multivariate analyses were performed with one-way ANOVA test and Cox proportional hazards model to identify powerful association and independency among prognostic factors. P values <0.05 were considered statistically significant.

   Results Top

The main clinicopathologic characteristics of the studied population as well as the associations with the “GL MB” parameter are listed in [Table 1]. Considering all the entertained subgroups (GL1 MB1, GL1 MB0, GL0 MB1, and GL0 MB0), the median follow-up was 17.8 months (range: 62–0). Among the 39 patients with GL malignant cells (GL1) (49%), bacterial microbiota was present (MB1) and absent (MB0) in 33 and 6 patients, respectively. In the group without GL cancer cells (GL0) (51%), MB1 was found in 32 and MB0 in 8 cases. At a median follow-up of 33.9 months (range: 2–77) of the 46 dead patients, 21 subjects were GL1 MB1, 2 GL1 MB0, 20 GL0 MB1, and 3 GL0 MB0; of the 33 alive subjects, 12 were GL1 MB1, 4 GL1 MB0, 12 GL0 MB1, and 5 GL0 MB0. The Kaplan-Meier model showed significant differences of OS between GL1 MB1 and GL1 MB0 groups (20.5 vs 45.8 months, respectively, P = 0.049) [Figure 4]. Precisely, in GL1 MB1 group, following surgery, there were 12 alive and 21 dead patients. For 7 alive patients, less than 10 months passed by from intervention. As for deaths, 10 occurred after 10 months from surgery, 13 after 20 months, 19 after 30 months, and 20 after 40 months. Concerning GL1 MB0 group, 2 deaths occurred after 19 and 24 months while 4 patients are still alive after 6, 38, 42, and 62 months. GL1 MB1 strongly correlated with advanced disease (T3-T4 with P = 0.049 and Stage 3-4 with P = 0.035) [Table 1]. At univariate analysis, the GL1 MB1 parameter resulted a significant prognostic factor for OS (P = 0.008) [Table 2]. Furthermore, multivariate analysis revealed GL1 MB1 as an independent prognostic factor of OS [P = 0.013 with an overall model fit of P < 0.001, [Table 3]. In addition, GL1 MB1 significantly associated with the preoperative diagnosis of H. pylori infection [P = 0.011, [Table 1]].
Figure 4: Difference of survivals between patients with intragastric copresence of cancer cells and microbiota (GL1 MB1) and subjects with exfoliated malignant cells but without microbiota (GL1 MB0)

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Table 1: Clinicopathologic characteristics of the 79 gastric cancer patients related with the combined “gastric lavage cancer cells/microbiota” (“GL1/GL0 MB1/MB0”) parameter

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Table 2: Univariate analysis of significant prognostic factors for overall survival

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Table 3: Multivariate analysis of independent prognostic factors for overall survival

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   Discussion Top

In the last decade, cytologic and molecular investigation of GL has provided interesting findings in terms of diagnosis, screening, prognosis, and treatment of GC patients.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[28],[29],[30] Concerning the cytologic aspect, as suggested by numerous authors, the oncologic value of GL derives from its privilege of collecting GC products released directly by the tumor avoiding hepatic clearance, a condition known under the name of Metastasis VI.[8],[9],[31] In the presence of a patent gastrointestinal tube, the exfoliation of malignant cells into the gastric lumen (Metastasis VI) strongly suggests the possibility that other cell elements have already migrated or infiltrated the surrounding tissue following the classical routes of metastasis (invasion through vascular or lymphatic channels, lymph nodes, direct contact, intraperitoneal or mesogastric seeding).[9] On the other hand, when obstruction by GC has occurred especially at cardia or pylorus, a number of cancerous cells, surviving for a long time due to a phenomenon called anoikis resistance, could colonize the gastric lumen, deposit on gastric or esophageal mucosa, and promote a metastasis.[11] Moreover, in most recent years, analysis of GL and stomach acid has been enriched with a further new perspective on GC research: the gastric bacterial MB.[18],[19],[20],[21],[22],[23],[24],[25] Concerning the gastric microbial community, H. pylori infection indeed plays a pivotal role in GC carcinogenesis.[18],[19],[20],[21],[22],[23],[24],[25],[32],[33] However, latest studies suggested that colonization of other non-H. pylori bacteria in the stomach (such as Propionibacterium acnes, Prevotella copri, and Eubacterium cylindroides) can also stimulate GC risk by producing proinflammatory cytokines such as IL 15 and lymphocytic gastritis.[34],[35],[36],[37] Taking a cue from such new literature data, for this study, we wanted to enrich our previously reported line of research (the cytopathologic analysis of GL from GC patients) by combining it with examination of intragastric MB: as a consequence, we assessed the cyto-microbiologic parameter of “GL MB.” In our patient population, analysis of this character provided original and interesting results. In fact, subjects showing GL1 and MB1 had poorer survival compared with GL1 MB0 group (20.5 vs 45.8 months, respectively, P = 0.049) [Figure 4]; such a result could confirm a pro-tumorigenic role of some gastric microbiota as suggested by previous studies.[34],[35],[36] This is also corroborated by the fact that, in our series, MB1 in conjunction with GL1 strongly correlated with tumor aggressiveness in advanced phase of disease (T3-T4 with P = 0.049 and Stage 3-4 with P = 0.035) [Table 1]. Furthermore, the GL1 MB1 parameter resulted a significant prognostic factor for OS in univariate analysis (P = 0.008, [Table 2]] and an independent prognostic factor of OS at multivariate analysis (P = 0.013 with an overall model fit of P < 0.001, [Table 3]). In other words, the absence of bacterial microbiota (MB0) in GL1 GC patients seemed to be a protective factor. In addition, GL1 MB1 was significantly associated with the preoperative diagnosis of H. pylori infection (P = 0.011, [Table 1]).

In the light of our results, the mixed cyto-microbiological test on GL seems quite interesting to perform in GC patients, especially from a prognostic and therapeutic point of view. Our findings, in fact, strengthening the carcinogenic role executed by Metastasis VI and H. pylori but also suggesting the cooperation between such features and the other non-H. pylori pro-oncogenic germs within the endogastric microenvironment, showed that GL1 MB1 GC patients had a poorer OS in comparison with GL1 MB0 GC subjects.[18],[19],[20],[21],[22],[23],[24],[25],[32],[33],[34],[35],[36] In this regard, the treatment of non-H. pylori bacteria could exert a conspicuous benefit for individuals with related precancerous gastric lesions (such as lymphocytic gastritis), just as already proven by antibiotic therapy for H. pylori infection.[30],[37] Further studies dealing with GC patients showing malignant endogastric exfoliation in combination with intragastric microbiota (GL1 MB1 GC subjects) are needed to corroborate our data.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Ai S, Sun F, Liu Z, Yang Z, Wang J, Zhu Z, et al. Change in serum albumin level predicts short-term complications in patients with normal preoperative serum albumin after gastrectomy of gastric cancer. ANZ J Surg 2019;89:E298-301.  Back to cited text no. 1
Kanaji S, Kakeji Y. Is laparoscopic distal gastrectomy a feasible procedure for elderly patients with gastric cancer? J Invest Surg 2019;31:546-7.  Back to cited text no. 2
Pilozzi E, Ferri M, Rapazzotti Onelli M, Mercantini P, Corigliano N, Duranti E, et al. Prognostic significance of 18q LOH in sporadic colorectal carcinoma. Am Surg 2011;77:38-43.  Back to cited text no. 3
Ferri M, Lorenzon L, Rapazzotti Onelli M, La Torre M, Mercntini P, Virgilio E, et al. Lymph node ratio is a stronger prognostic factor than microsatellite instability in colorectal cancer patients: Results from a 7 year follow-up study. Int J Surg 2013;11:1016-21.  Back to cited text no. 4
Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394-424.  Back to cited text no. 5
Lemini R, Jorgensen MS, Attwood K, Almerey T, Elli EF, Colibaseanu DT, et al. Racial disparities in outcomes among Asians with gastric cancer in the USA. Anticancer Res 2020;40:881-9.  Back to cited text no. 6
Virgilio E, Giarnieri E, Giovagnoli MR, Montagnini M, Proietti A, D'Urso R, et al. Gastric lavage malignant cells (yGL) and hypohemoglobinemia (yAnemia) as new systems of tumor regression grading and prognostic prediction for gastric cancer after neoadjuvant treatment. Anticancer Res 2019;39:1019-27.  Back to cited text no. 7
Virgilio E, Giarnieri E, Montagnini M, Villani S, Giovagnoli MR, Mercantini P, et al. Advances in intraluminal exfoliative cytology of gastric cancer: Oncologic implication of the sixth metastatic route (Metastasis VI). Anticancer Res 2019;39:4019-22.  Back to cited text no. 8
Virgilio E, Giarnieri E, Giovagnoli MR, Montagnini M, Proietti A, D'Urso R, et al. Presence of cancer cells in gastric lavage of gastric cancer patients as an indicator of advanced disease, predictor of tumour aggressive phenotype and independent prognostic factor for poor survival: The endoluminal metastatic pathway of gastric cancer and GL0/GL1 classification. Cytopathology 2018;29:41-8.  Back to cited text no. 9
Virgilio E, Giarnieri E, Giovagnoli MR, Montagnini M, Proietti A, D'Urso R, et al. Early gastric cancer exfoliating into gastric lavage (GL1 EGC) shows a more aggressive behavior and poorer survival compared to the non-exfoliative counterpart (GL0 EGC). Anticancer Res 2017;37:4199-203.  Back to cited text no. 10
Virgilio E, Balducci G, Mercantini P, Giarnieri E, Giovagnoli MR, Mercantini P, et al. Preoperative gastric lavage in gastric cancer patients undergoing surgical, endoscopic or minimally invasive treatment: An oncological measure preventing peritoneal spillage of intragastric cancer cells and development of related metastases. Med Hypotheses 2018;114:30-4.  Back to cited text no. 11
Virgilio E, Proietti A, D'Urso R, Cardelli P, Giarnieri E, Montagnini M, et al. Measuring intragastric tumor markers in gastric cancer patients: A systematic literature review on significance and reliability. Anticancer Res 2017;37:2817-21.  Back to cited text no. 12
Virgilio E, Giarnieri E, Montagnini M, D'Urso R, Proietti A, Mesiti A, et al. Detection of cancer cells and tumor markers in gastric lavage of patients with gastric cancer: Do these findings have a clinicopathological significance and oncological implication? Med Hypotheses 2016;94:1-3.  Back to cited text no. 13
Virgilio E, Giarnieri E, Montagnini M, D'Urso R, Proietti A, Mesiti A, et al. Analyzing gastric lavage of gastric cancer patients: A prospective observational study on cytopathology and determination of intragastric CEA, Ca 19.9, Ca 72.4 and Ca 50. Acta Cytol 2016;60:161-6.  Back to cited text no. 14
Virgilio E, Balducci G, Mercantini P, Giarnieri E, Giovagnoli MR, Montagnini M, et al. Utility of nasogastric tube for medical and surgical oncology of gastric cancer: A prospective institutional study on a new and precious application of an old and economic device. Anticancer Res 2018;38:433-9.  Back to cited text no. 15
Virgilio E, Giarnieri E, Giovagnoli MR, Montagnini M, Proietti A, D'Urso R, et al. Gastric juice microRNAs as potential biomarkers for screening gastric cancer: A systematic review. Anticancer Res 2018;38:613-6.  Back to cited text no. 16
Virgilio E, Giarnieri E, Giovagnoli MR, Montagnini M, Proietti A, D'Urso R, et al. Long non-coding RNAs in the gastric juice of gastric cancer patients. Pathol Res Pract 2018;214:1239-46.  Back to cited text no. 17
Pichon M, Burucoa C. Impact of the gastro-intestinal bacterial microbiome on Helicobacter-associated diseases. Healthcare (Basel) 2019;7:34.  Back to cited text no. 18
Engstrand L, Graham DY. Microbiome and gastric cancer. Dig Dis Sci 2020;65:865-73.  Back to cited text no. 19
Schütte K, Malfertheiner P, Schulz C. What is the relevance of gastric microbiota beyond H. pylori? Curr Treat Options Gastro 2019;17:619-27.  Back to cited text no. 20
Schulz C, Schütte K, Mayerle J, Malfertheiner P. The role of the gastric bacterial microbiome in gastric cancer: Helicobacter pylori and beyond. Ther Adv Gastroenterol 2019;12:1756284819894062.  Back to cited text no. 21
Ferreira RM, Pereira-Marques J, Pinto-Ribeiro I, Costa JL, Carneiro F, Machado JC, et al. Gastric microbial community profiling reveals a dysbiotic cancer-associated microbiota. Gut 2018;67:226-36.  Back to cited text no. 22
Zilberstein B, Quinitanilha AG, Santos MA, Pajecki D, Moura EG, Arruda Alves PR, et al. Digestive tract microbiota in healthy volunteers. Clinics (Sao Paulo) 2007;62:47-54.  Back to cited text no. 23
Aviles-Jimenez F, Vazquez-Jimenez F, Medrano-Guzman R, Mantilla A, Torres J. Stomach microbiota composition varies between patients with non-atrophic gastritis and patients with intestinal type of gastric cancer. Sci Rep 2014;4:4202.  Back to cited text no. 24
Thorell K, Bengtsson-Palme J, Liu OH, Palacios Gonzales RV, Nookaew I, Rabeneck L, et al. In vivo analysis of the viable microbiota and Helicobacter pylori transcriptome in gastric infection and early stages of carcinogenesis. Infect Immun 2017;85:e00031-17.  Back to cited text no. 25
Hashemi MR, Rahnavardi M, Bikdeli B, Dehghani Zahedani M, Iranmanesh F. Touch cytology in diagnosing Helicobacter pylori: Comparison of four staining methods. Cytopathology 2008;19:179-84.  Back to cited text no. 26
Jiang Y, Tu R, Lu J, Zhang Y, Zhu J, Tang W, et al. Proposed modification of the 8th ed.ition of the AJCC staging system for gastric cancer. J Invest Surg 2020;33:932-8.  Back to cited text no. 27
Lorusso D, Linsalata M, Pezzolla F, Berloco P, Osella AR, Guerra V, et al. Duodenogastric reflux and gastric mucosal polyamines in the non-operated stomach and in the gastric remnant after Billroth II gastric resection. A role in gastric carcinogenesis? Anticancer Res 2000;20:2197-201.  Back to cited text no. 28
Virgilio E, Proietti A, D'Urso R, Cardelli P, Giarnieri E, Giovagnoli MR, et al. Elevated gastric juice carbohydrate antigen (Ca 72.4) is an independent prognostic factor of poor survival for gastric cancer patients. Anticancer Res 2020;40:1691-5.  Back to cited text no. 29
Virgilio E, Giarnieri E, Giovagnoli MR, Montagnini M, Villani S, Proietti A, et al. Combined analysis of intragastric malignant exfoliation and Ca 72.4 concentration in stomach adenocarcinoma: The “GL1 Ca 72.4” parameter. Acta Cytol 2020;64:563-71.  Back to cited text no. 30
Virgilio E, D'Antonio C, Balducci G. Mesogastrium recurrence as expression of the fifth metastatic route of gastric cancer. Med Hypotheses 2013;80:498-500.  Back to cited text no. 31
Chung AY, Chow PK, Yu WK, Ho JM, Chan HS, Wong WK, et al. Prevalence of Helicobacter pylori in gastric cancer in a South-East Asian population by 14C-urea breath test. ANZ J Surg 2001;71:574-6.  Back to cited text no. 32
Benberin V, Bektayeva R, Karabayeva R, Lebedev A, Akemeyeva K, Paloheimo L, et al. Prevalence of H. pylori infection and atrophic gastritis among symptomatic and dyspeptic adults in Kazakhstan. A hospital-based screening study using a panel of serum biomarkers. Anticancer Res 2013;33:4595-602.  Back to cited text no. 33
Gunathilake MN, Lee J, Choi IJ, Kim YI, Ahn Y, Park C, et al. Association between the relative abundance of gastric microbiota and the risk of gastric cancer: A case-control study. Sci Rep 2019;9:13589.  Back to cited text no. 34
Dias-Jàcome E, Libanio D, Borges-Canha M, Galaghar A, Pimentel-Nunes P. Gastric microbiota and carcinogenesis: The role of non-helicobacter pylori bacteria-a systematic review. Rev Esp Enferm Dig 2016;108:530-40.  Back to cited text no. 35
Petra CV, Rus A, Dumitraşcu DL. Gastric microbiota: Tracing the culprit. Clujul Med 2017;90:369-76.  Back to cited text no. 36
Monstein HJ, Tiyejung A, Kraft CH. Profiling of bacterial flora in gastric biopsies from patients with Helicobacter pylori-associated gastritis and histologically normal control individuals by temperature gradient gel electrophoresis and 16S rDNA sequence analysis. J Med Microbiol 2000;49:817-22.  Back to cited text no. 37

Correspondence Address:
Edoardo Virgilio
Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43125
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JOC.JOC_238_20

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2], [Table 3]


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