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The role of Endoscopy in Gastric Cancer
Fergal DonnellanGastroenterologist
VGH
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Endoscopy
Endoscopic Ultrasound
Linitus Plastica
Early Gastric Cancer
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Endoscopic biopsy
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All suspicious ulcers should be biopsied
Consider patient's history and demographic features Numerous biopsies - Increasing from one to seven increases sensitivity
from 70% to 98%
Cytology adds little to the diagnostic yield and is not routinely recommended
Repeat endoscopy following acid suppression
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Endoscopic Location
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Tumors arising at the GE junction, or in the cardia of the stomach within 5 cm of the GEJ that extend into the GEJ or esophagus (the so-called Siewert III) are staged as esophageal cancer
Tumors that are within 5 cm of the GEJ that do not extend into the esophagus are staged as gastric cancers
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Staging
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Primary tumor (T)
Tis Carcinoma in situ: intraepithelial tumor without invasion of the lamina propria
T1
T1a
T1b
Tumor invades lamina propria, muscularis mucosae, or submucosa
Tumor invades lamina propria or muscularis mucosae
Tumor invades submucosa
T2 Tumor invades muscularis propria
T3 Tumor penetrates subserosal connective tissue without invasion of visceral peritoneum or adjacent structures
T4 Tumor invades serosa (visceral peritoneum) or adjacent structures
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T1 and T2 - Consideration for surgery
T1a and T1b- Consideration for endoscopic resection
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No single gold standard
EUS
CT
MRI
PET
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EUS and T Stage
EUS staging versus histopathology
Sensitivity and Specificity rates for distinguishing T1 from T2 cancers with EUS were 85 and 90%, respectively
Sensitivity and Specificity for distinguishing T1/2 versus T3/4 tumors were 86 and 90%, respectively
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EUS and N Stage
Sensitivity and specificity rates for detection of malignant lymph nodes were 83 and 67%, respectively
EUS guided FNA possible
EUS cannot be considered optimal for distinguishing positive versus negative lymph node status
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EUS and M Stage
Routine use of staging EUS can sometimes alter the therapeutic plan because of the finding of otherwise occult distant metastases
Useful to identify and biopsy ascites or left lobe liver lesions
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T stage N stage
EUS 75% - 92% 30 – 90%
CT 43 – 82%
MDCT 77.1 - 88.9% 67.1%
MRI 53% - 87.9% 50% - 65.4%
PET 58.1% - 95.9% 55.1 – 73.3%
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Both EUS and MDCT show high accuracy for overall and each T stage
MRI seemed to have better performance, but the number of studies is limited
FDG-PET is not able to properly evaluate the depth of invasion
In preoperative N staging, the diagnostic accuracy of EUS, MDCT, and MRI is not sufficient to appropriately assess LN status
In preoperative M staging, MDCT and FDG-PET showed similar diagnostic accuracies
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EUS should be considered as part of the staging process for gastric cancer and complimentary to other modailities
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Linitus Plastica(Diffuse type gastric cancer)
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Linitis Plastica (Diffuse type gastric cancer)
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Superficial mucosal biopsies may be negative
Tunnelled or bite on bite biopsies
EUS guided mucosal biopsies
EUS FNA/FNB
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Early Gastric Cancer
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Defined as an adenocarcinoma that is restricted to the mucosa or submucosa, irrespective of lymph node metastasis (T1, any N)
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Incidence of early gastric cancer (EGC), as well as the proportion of gastric adenocarcinomas that are EGCs, vary depending on the population
In Japan,50% of gastric adenocarcinomas are EGC
In Korea, 25 to 30% of gastric adenocarcinomas are EGCs
In Western countries, up to 20% of gastric adenocarcinomas are EGCs
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Endoscopic resection may be considered both a staging procedure and a treatment
En bloc resection permits T staging of the tumor
Limited by risk of lymph node metastases
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Predictors of Lymph Node Metastasis in Western Early Gastric CancerJ Gastrointest Surg. 2015
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67 patients with pT1 lesions underwent surgery without neoadjuvant treatment
LN metastases were present in 15/67 (22 %) pT1 tumors- 1/23 (4 %) T1a tumors- 14/44 (32 %) T1b tumors
Lymphovascular invasion and positive nodes on EUS were the only factors that predicted LN metastasis
T1a tumors without LVI had a 0 % rate of positive LN
T1b tumors with LVI had a 64.3 % rate of positive LN
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Conclusion
Early Gastric Cancer limited to the mucosa, without evidence of LVI, and N0 on EUS, may be considered for limited resection
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Endoscopic resection techniques
- Endoscopic mucosal resection
- Endoscopic submucosal dissection
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EUS and T stage for EGC
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Incorrect staging
72% accurate for T staging - 19% were overstaged - 9% were understaged
Opinion divided between EUS prior to endoscopic resection