Gastric Intestinal Metaplasia and Early Gastric Cancer: Screening, Surveillance, and Endoscopic Therapy Consultant for: Olympus Medtronic US Endoscopy Disclosures Joo Ha Hwang, MD, PhD Associate Professor of Medicine Chief, Gastroenterology Harborview Medical Center University of Washington, Seattle 6 th Annual Asian Health Symposium, UCSF Friday, October 6, 2017 Discuss: Objectives Which patients should be considered for gastric cancer screening How to perform gastric cancer screening What intervals should screening be performed What to do when an early gastric cancer is suspected Endoscopy resection vs. surgery ASGE Guidelines We suggest screening EGD for gastric cancer in new U.S. immigrants from high-risk regions around the world, such as Korea, Japan, China, Russia, and South America, especially if there is a family history of gastric cancer in a first-degree relative. Stomach cancer is the 3 rd leading cause of cancer death worldwide Race and ethnicity considerations in GI Ethnic issues in endoscopy (ASGE SOP) 2010 Endoscopy - GIE 2015
Incidence of Gastric Cancer 2004-2009 Incidence (per 100,000) 500 450 400 350 300 250 200 150 100 50 0 Cancer Incidence Stomach and Colorectal Cancer (men) Korea vs. US Korean-Stomach Cancer Korean-Colorectal Cancer US-Colorectal Cancer US-Stomach Cancer http://seer.cancer.gov/statfacts/html/stomach.html Lin Gomez et al. J Natl Cancer Inst 2013 Age http://globocan.iarc.fr WHO GLOBOCAN 2012 Is screening effective? Screening programs in Japan and Korea have increased survival for gastric CA 80 70 60 50 40 30 20 10 0 26.9 5 year survival 62.1 57.7 67 US vs. Korea Stage Distribution and Relative Survival Rates Jung et al. Cancer Res Treat 2013
Endoscopy of GIM What is gastric intestinal metaplasia? Precancerous lesion for gastric cancer Gastric CA is the 3 nd leading cause of cancer death worldwide High incidence in eastern Asia, eastern Europe, and S. America GIM has increase risk of gastric cancer if it occurs in the setting of atrophic gastritis Patients with IM have 6-8 fold increased risk of gastric cancer IM does not regress following h. pylori therapy May slow progression Additional risk factors Incomplete-type IM Both antral and body involvement IM involving over 20% of the gastric mucosa Family history (1 st degree relative) Smoking Correa s Cascade Peleteiro and Lunet (2011) http://www.intechopen.com/books/gastritis-and-gastric-cancer-new-insights-in-gastroprotection-diagnosisand-treatments/role-of-genetic-and-environmental-risk-factors-in-gastric-carcinogenesis-pathway
ASGE Guideline Management of premalignant and malignant conditions of the stomach GIE 2015 We suggest surveillance endoscopy for patients with GIM who are at increased risk of gastric cancer due to ethnic background or family history. Optimal surveillance intervals have not been extensively studies and should be individualized. We recommend endoscopic resection and surveillance endoscopy for patients with confirmed GIM with HGD when feasible. Kim, Liang, Bang and Hwang, Screening and Surveillance for Gastric cancer in the United States: Is it needed? GIE 2016
Criteria for ESD/Surgery ESD Accepted criteria for endoscopic resection (EMR/ESD) Expanded criteria for endoscopic resection (EMR/ESD) Absolute criteria for surgery ESD ESD Video
Resected specimen ESD vs Surgery for EGC Chiu et al. Surg Endosc 2012 Perioperative Results Who s at risk? Median operating time (range) Median hospital stay (range) Overall complication rate ESD N=74 90 (45-360) 3.0 (2-10) Gastrectomy N-40 265 (150-360) 9.9 (6-26) P value <0.001 <0.001 5.4% 32.5% <0.001 Chiu et al. Surg Endosc 2012;26:3584-3591
Summary Gastric intestinal metaplasia is a premalignant lesion. Surveillance of GIM should be performed in patients who have extensive GIM or have additional risk factors for gastric cancer. HGD and early gastric cancer can be managed endoscopically without the need for surgery Thank you