Gastric Intestinal Metaplasia Consultant for: and Early Gastric - - PDF document

Joo Ha Hwang, MD, PhD

Associate Professor of Medicine Chief, Gastroenterology Harborview Medical Center University of Washington, Seattle

6th Annual Asian Health Symposium, UCSF Friday, October 6, 2017

Gastric Intestinal Metaplasia and Early Gastric Cancer: Screening, Surveillance, and Endoscopic Therapy

Disclosures

• Consultant for:

– Olympus – Medtronic – US

Endoscopy

Objectives

Discuss:

• 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

AS GE 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 S

• uth

America, especially if there is a family history of gastric cancer in a first-degree relative.

Ethnic issues in endoscopy (ASGE SOP) 2010

Stomach cancer is the 3rd leading cause

• f cancer death

worldwide

Race and ethnicity considerations in GI Endoscopy - GIE 2015

Incidence of Gastric Cancer 2004-2009

• http://seer.cancer.gov/statfacts/html/stomach.html

Lin Gomez et al. J Natl Cancer Inst 2013

Cancer Incidence

S tomach and Colorectal Cancer (men) Korea vs. US

50 100 150 200 250 300 350 400 450 500

Korean-Stomach Cancer Korean-Colorectal Cancer US-Colorectal Cancer US-Stomach Cancer

Incidence (per 100,000) Age http://globocan.iarc.fr WHO – GLOBOCAN 2012

Is screening effective?

• S

creening programs in Japan and Korea have increased survival for gastric CA

26.9 62.1 57.7 67 10 20 30 40 50 60 70 80

5 year survival

US

• vs. Korea

S tage Distribution and Relative S urvival 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 3nd 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%

• f the gastric mucosa

– Family history (1st degree relative) – S

moking

Correa’s Cascade

Peleteiro and Lunet (2011)

http://www.intechopen.com/books/gastritis-and-gastric-cancer-new-insights-in-gastroprotection-diagnosis- and-treatments/role-of-genetic-and-environmental-risk-factors-in-gastric-carcinogenesis-pathway

AS GE 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

• Accepted criteria for endoscopic resection (EMR/ESD)

Expanded criteria for endoscopic resection (EMR/ESD) Absolute criteria for surgery

ESD ESD ESD Video

Resected specimen ESD vs Surgery for EGC

Chiu et al. Surg Endosc 2012

Perioperative Results

ESD N=74 Gastrectomy N-40 P value

Median operating time (range) 90 (45-360) 265 (150-360) <0.001 Median hospital stay (range) 3.0 (2-10) 9.9 (6-26) <0.001 Overall complication rate 5.4% 32.5% <0.001

Chiu et al. Surg Endosc 2012;26:3584-3591

Who’s at risk?

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