GIT J club EGC MENBI.

1. Kurdistan Board GEH J Club
Supervised by:
Professor Dr.Mohamed Alshekhani.
MBChB-CABM-FRCP-L,EBGH.
Japan Gastroenterological Endoscopy Society

2. • Gastric cancer is the third leading cause of cancer death
worldwide.
• Early detection / accurate diagnosis of mucosal cancer is
desirable in order to achieve decreased mortality;
• cause-specific survival of patients with early gastric cancer
> 95%.
• Endoscopy is the functional modality to detect early
cancer; but is not definitive when using conventional
white-light imaging.
• Magnifying (M-NBI), a novel endoscopic technology, is a
powerful tool for characterizing gastric mucosal lesions
because it can visualize the microvascular architecture &
microsurface structure.

3. • To date, many reports on the diagnosis of early gastric
cancer by M-NBI, including multicenter prospective
randomized studies conducted in Japan, have been
published in peer-reviewed international journals.
• Based on these published data, we devised a proposal for
a diagnostic strategy for gastric mucosal cancer using M-
NBI to simplify the process of diagnosis & improve
accuracy.

27. Conclusion:
• Magnifying Endoscopy is proven to be a key modality for
effective diagnosis of EGC.
• It is not widely used because of the absence of unified
diagnostic criteria.
• The clinical societies hope this algorithm (MESDA-G)
terminology will be generally / widely used in clinical
practice&may enhance early diagnosis of gastric cancer,
resulting in reduction of gastric cancer-related death
worldwide.

28. OGD in Japan vs elswhere:
• Prevalence of screening exam was higher in Japanese than
international.
• Japanese endoscopists noted that endoscopicmucosal
atrophy was the most significant risk factor for GC,
whereas international endoscopists paid more attention to
clinical information such as age, symptoms&family history.
• Antispasmodics, mucolytics, defoaming agents were used
more frequently in Japanese institutions.
• The exam time was similar (mostly 5–10 min).
• Japanese endoscopists took more pictures (>20) than
international endoscopists (≤20).

29. OGD in Japan vs elswhere:
• In Japan, biopsy were more frequently taken from areas of
mucosal discoloration, unevenness or spontaneous
bleeding rather than from obvious endoscopic lesions
such as ulceration or polyps.
• In most Japanese institutions, one or two biopsy
specimens were taken per lesion, compared with ≥three in
international institutions.
• There were some discrepancies between Japanese &
international institutions. Thus, standardization is required
for adequate risk assessment, proper techniques&
knowledge of endoscopic diagnosis of EGC.

37.  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

38. Endoscopic Location

39.  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

42. Staging

43. 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

44.  T1 and T2
- Consideration for surgery
 T1a and T1b
- Consideration for endoscopic resection

45.  No single gold standard
 EUS
 CT
 MRI
 PET

46. 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

47. 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

48. 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

49. 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%

50.  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

51. EUS should be considered as part of the staging process
for gastric cancer and complimentary to other modailities

52. Linitus Plastica
(Diffuse type gastric cancer)

53. Linitis Plastica
(Diffuse type gastric cancer)

54.  Superficial mucosal biopsies may be negative
 Tunnelled or bite on bite biopsies
 EUS guided mucosal biopsies
 EUS FNA/FNB

56. Early Gastric Cancer

57.  Defined as an adenocarcinoma that is restricted to
the mucosa or submucosa, irrespective of lymph node
metastasis (T1, any N)

58.  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

59.  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

60. Predictors of Lymph Node Metastasis in Western Early
Gastric Cancer
J Gastrointest Surg. 2015

61.  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

62. Conclusion
Early Gastric Cancer limited to the mucosa, without
evidence of LVI, and N0 on EUS, may be considered for
limited resection

63.  Endoscopic resection techniques
- Endoscopic mucosal resection
- Endoscopic submucosal dissection

65. EUS and T stage for EGC

66.  Incorrect staging
 72% accurate for T staging
- 19% were overstaged
- 9% were understaged
 Opinion divided between EUS prior to endoscopic
resection