Download An Audit of Early Gastric Cancer - Northern England Clinical Networks

Early gastric cancer in the
County Durham and Tees Valley
Region – an audit of clinical
practice
Dr Poonam Valand, Foundation Year Two
Dr Anjan Dhar, Consultant Gastroenterologist
COUNTY DURHAM AND DARLINGTON NHS FOUNDATION
TRUST
Introduction

Oesophago-gastric cancer:

5th most common malignancy and 4th most common cause of
cancer related deaths in the UK.

Incidence increasing in many Western countries (13,500 people
diagnosed in 2011 ,Cancer Research UK).

28 Cancer Networks in England and 2 in Wales.

Prognosis:

Poor
 1-year survival rates approx 30%
 5-year survival rate 13%
Early Gastric Cancer –
a comparison between the East and West

What is early gastric cancer (EGC)?


Cancer which is limited to the mucosa and of the
submucosa.
Treatment of EGC using endoscopy pioneered in Japan, by
endoscopic mucosal resection (>10,000 cases detected each
year).
 corresponds to approximately 50% of all gastric cancers.

Significantly less numbers in the West compared to the East
(Japan, China, Korea).

Technological advancements in endoscopic imaging and
treatment methods in the East:


New endoscopic imaging techniques more widely used.
Endoscopic mucosal resection (EMR) and endoscopic
submucosal dissection (ESD) well established.
National Esophagogastric Cancer Audit 2012
Specialist MDT discussions Including
involvement of palliative Care
2 pathologists to assess and
diagnose High Grade Dysplasia
Cancer Network to have access to
endoscopic therapies
Careful assessment of patients for
palliative chemotherapy (older age
and low performance status)
Endoscopic Mucosal Resection

First case report of EMR published in 1984.

A treatment option for early-stage gastric carcinoma.

used diagnostically and therapeutically in both upper and lower GI tracts
 significantly lower mortality and morbidity than surgery.
Surgical gastrectomy was the only method of treatment for EGC before
development of endoscopic mucosal resection (EMR) or endoscopic
mucosectomy.


Research shows :

many early gastric cancer patients did not have any metastatic lesions.
 gastrectomy for resection of regional lymph nodes is not always required.
 Less invasive than surgical gastrectomy without sacrificing possibility of a
cure in early lesions.
Endoscopic Mucosal Resection

Involves local excision of lesions confined to the mucosa.

may even have a role in the treatment of submucosal lesions in the GI tract.
Aims of this Audit

Proportion of patients with Gastric Cancer who were at T1/T2 stage
at time of diagnosis.

Main methods of referral.

Modality of treatment offered.

Histology at first endoscopy and post- op.

Number of cases treated by EMR.
Is EMR something that should be more widely practiced?
Methods

Patients with gastric cancer identified from the James Cook University Hospital Central
Upper GI Cancer MDT database.

Period of Audit: January 2011 – January 2012.

4 hospitals:





Out of 105 patients 12 were diagnosed to have early gastric cancer based on:


County Durham and Darlington Foundation Trust
North Tees Hospital
Hartlepool Hospital
James Cook University Hospital.
patients presenting with High Grade Dysplasia to T1/T2-NO-MO staging.
A 13 point proforma was created to collect data on:





clinical presentation
Alcohol
route of referral
pre and post interventional histology
final MDT decision
smoking
family history
endoscopy findings,
other investigations,
survival in months.
Results

12 of 105 gastric cancers were EGC (11.4%).

mean age 74.8yrs (range 62-83yrs).

M:F=9:3.

On CT staging, all lesions were T1/T2, N0, M0 lesions.

Endoscopic resection was carried out in only 1 patient, and all
others had surgery.
Results
Symptoms at Presentation
Initial Endoscopy Findings
17%
Suspicious Lesion
Ulcer
83%
Pre-Op Endoscopic Histology
Adenocarcinoma
High Grade Dysplasia
SMC
25%
33%
42%
Endoscopic Mucosal Resection (EMR)
Standard
endoscopic view
Chromoendoscopy
Marking
Post
resection
12 mth follow up
Resecting
Conclusions/Recommendations

Approximately 10% of gastric cancers are early gastric cancers in
our region.

Endoscopic treatment is not frequently carried out, as in eastern
countries.

There may be an opportunity to increase endoscopic resections for
these lesions.