endoscopic assessment of gastric cancer · bsg gastric cancer guidelines 2019 intent to screen and...
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ENDOSCOPIC ASSESSMENT OF GASTRIC CANCER
Eric Lam MD FRCPC FASGE October 5, 2019 BC Cancer Surgery Network Fall Update
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FACULTY/PRESENTER DISCLOSURE
Faculty: Eric Lam
Relationships with commercial interests Grants/Research Support: None Speakers Bureau/Honoraria: Pendopharm Consulting Fees: Olympus Canada Other:
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MANAGING POTENTIAL BIAS
No mention of proprietary techniques or imaging modalities
Not speaking about any products used in ESD
Relationships do not affect my choices in developing content
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OBJECTIVES
Recognize the typical gastric cancer morphologies and precursor lesions
Identify the pathological significance of both benign and malignant histologies
Describe criteria for endoscopic evaluation and critical components of an endoscopic report for gastric cancer
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GASTRIC CANCER EPIDEMIOLOGY
Fourth most common incident cancer in the world
Second leading cause of cancer related mortality worldwide
Majority of prevalent cases in east Asia 3.5 – 7.8/100,000 US 65.9/100,000 Korea
On the decline Non Cardia GC – due to declining H. pylori infection
Karimi P. et al. Cancer Epidemiol Biomarkers Prev 2014 23(5):700-713
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GASTRIC CANCER
Microscopically resemble intestinal mucosa
Many if not all arise from chronic gastritis
Oxyntic atrophy/hypochlorhydria
Distinct differences result in differences in natural history and treatment
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GASTRIC CANCER ORIGIN AND CLASSIFICATION Complex interaction between The etiologic agents of gastritis Gastrin effect on ECL cells/histamine
release Histamine affects on antral cells Differentiation differences between
antral and oxyntic mucosa
Classification schemes Do not explain all forms of gastric
carcinoma
Waldum HL, Fossmark R. Int J Mol Sci 2018; 19(12): 4109
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GASTRITIS TO HYPERGASTRINEMIA
Etiologic agents of chronic gastritis Helicobacter pylori Other infectious agents (EBV) Autoimmune Dietary factors
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GASTRITIS TO HYPERGASTRINEMIA
Hypergastrinemia Trophic hormone resulting in extrachromaffin cell growth Origin of type I gastric carcinoids Affects exocrine differentiation Two main growth patterns dependent on which cells involved
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LAUREN CLASSIFICATION
Intestinal type (Glandular growth pattern) Result of chronic gastritis Origins in oxyntic mucosa stem cells in the isthmus of the gastric pit Histamine mediated
Typically has precursor lesions that can be identified microscopically/endoscopically Chronic active gastritis
Atrophic gastritis/pernicious anemia
Intestinal metaplasia
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LAUREN CLASSIFICATION
Diffuse type (Infiltrative growth pattern) Origins in ECL cells Paracrine effects the antral mucosa cells Epithelial cell adhesion (E cadherin) Hereditary CDH1 Gene mutation
Somatic mutations leading to E cadherin loss
All gastric cancers have neuroendocrine testing Synaptophysin and chromogranin A
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MACROSCOPIC DISTRIBUTION
GE Junctional tumours Arising from specific cell type vs metaplasia?
Tumours distal to the cardia Oxyntic origins (glandular growth pattern) Antral origins (infiltrative growth pattern)
Distribution of antral and oxyntic cells less demarcated than once thought
Waldum HL, Fossmark R. Int. J. Mol. Sci. 2018;19:4109
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LAUREN CLASSIFICATION
Does not account for about 15% of gastric carcinomas GE Junctional tumours Microsatellite unstable tumors in Lynch syndrome Gastric carcinoma with lymphoid stroma (Medullary carcinomas)
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WHAT IS THE ENDOSCOPIC PRESENTATION OF THE SUBTYPES OF GASTRIC CANCER?
Polypoid
Fungating
Ulcerating
Infiltrating Linitis plastica
Borrmann R. Geschwulste des Magens und Duodenums. Springer, Berlin, Germany, 1926
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BIOPSYING GASTRIC CANCER
Multiple biopsies necessary for diagnosis and IHC Eight biopsies minimum to get > 90% probability of enough tissue for HER-2 testing
Biopsying on the edge of an ulcer Scirrhous cancers might have marked fibrosis Need to follow gastric ulcer to resolution
EUS assisted biopsies
Kaye P, et al., Histopathology 2019; 74(6):959-963
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WHO CLASSIFICATION
More related to microscopic morphology Tubular Papillary >50% of the involved area contains papillary structures
Higher lymphovascular invasion
Mucinous Signet ring cell
Loose association with the Lauren classification
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JAPANESE CLASSIFICATION
Classification into differentiated and undifferentiated
Differentiated Well or moderately differentiated Tubular or papillary subtype
Undifferentiated Poorly or signet ring differentiation Mucinous adenocarcinoma
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JAPANESE CLASSIFICATION
Mixed type Refers to mixed differentiation Differentiated mixed with undifferentiated component Behaves like differentiated
Undifferentiated type predominant Behaves like undifferentiated
Is associated with higher LNM or LVI than pure type gastric cancer
Bang CS, Baik GH. Clin Endosc 2019;52(1):30-35
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INVESTIGATION OF SYMPTOMS VS SCREENING Symptoms that warrant investigation New onset dyspepsia Anemia Weight loss
Screening Not approved but done for a variety of reasons Family history of gastric cancer
Patient from high prevalence area
Chronic dyspepsia
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EXPANDED SCREENING
BSG gastric cancer guidelines 2019
Intent to screen and survey high risk patients Family history Known intestinal metaplasia proximal to antrum Prior history of gastric dysplasia Known atrophic gastritis/pernicious anemia
Might increase the chances of picking up early gastric cancer
Banks M, et al. Gut 2019;68:1545-1575
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GASTRIC POLYPS
Usually found incidentally on upper endoscopy
Rarely symptomatic
Seen in about 6% of upper endoscopic procedures
Classification and management depends on cellular type
Carmack SW, et al. Am J Gastroenterol 2009;104(6):1524
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GASTRIC POLYPS
Fundic gland polyps
Hyperplastic polyps
Gastric adenomas
Gastric neuroendocrine tumors (carcinoids)
Inflammatory fibroid polyps
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FUNDIC GLAND POLYPS
Very common finding in the West Most FGP are sporadic Associated with PPI usage H. pylori rarely seen in association with FGP Almost all asymptomatic and range from 1-8mm in size
PPI induced FGP will regress with discontinuation of PPI
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SYNDROMIC FUNDIC GLAND POLYPS
Familial Adenomatous Polyposis 20 – 100% will have FGP 30-50% will show dysplasia typically low grade and rarely progress to gastric
cancer Carpeting FGP
Polyps > 10mm to rule out malignancy
Ulcerated FGP
Bianchi LK, et al. Clin Gsatroenterol Hepatol 2008;6(2):180 Mankaney G, et al. Fam Cancer 2017 16(3):371-376
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HYPERPLASTIC POLYPS
Hyper-regenerative epithelium in response to chronic inflammatory stimulus Atrophic gastritis H. pylori Sites adjacent to gastroenterostomy Adjacent to chronic ulcer/erosion
Most are asymptomatic Some cause bleeding Intermittent pyloric obstruction Typically small 5 – 15mm in the antrum
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MALIGNANT POTENTIAL OF HYPERPLASTIC POLYPS
Follows hyperplasia-dysplasia-carcinoma sequence
Transformation to dysplasia 2-19%
Higher risk Pedunculated lesions Size >10mm
Biopsies should be take around the polyp to look for dysplasia in adjacent mucosa
Han AR, et al. Gut Liver 2009;3(4):271-5 Terada T. Med Oncol 2011;28(4):941-4.
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GASTRIC ADENOMA
Seen in both chronic inflammatory states and familial clustering
Can occur anywhere in the stomach
Risk of malignant transformation increases With increased size of lesion > 2cm Presence of severe dysplasia Annual incidence 0.6% for mild/moderate dysplasia to 6% for severe dysplasia
Best removed by ESD for lesions >10mm
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ADDITIONAL MALIGNANT HISTOLOGIES
Metastatic disease Breast adenocarcinoma Melanoma
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WHAT GOES IN A GOOD ENDOSCOPY REPORT Concise, accurate and descriptive
More description better for all physicians involved with patient care Endoscopic pictures extremely valuable Video recordings even better
Conditions that aid in situations where procedures need to be repeated
Documentation of complications and adverse events
Plan of action
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A. Palor B. Loss of gastric folds C. Prominence of the vessels D. Atrophic border
Chronic Atrophic Gastritis
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BIOPSY PROTOCOL IN SUSPECTED INTESTINAL METAPLASIA Extent of intestinal metaplasia confers risk of intestinal type of adenocarcinoma
Although IM can be detected endoscopically, more difficult with non magnifying scopes
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SYDNEY PROTOCOL
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DESCRIPTION OF THE LESION
Location Distance from GE junction to the
proximal extent Anatomical location of the lesion in the
stomach Which wall of the stomach
Size of the lesion Open forceps 8mm Estimation of lesion relative to the
circumference of the stomach
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DESCRIPTION
Relevant common anatomical variations Presence of hiatus hernia/Schatzki ring Presence/type of previous surgery
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DESCRIPTION: MORPHOLOGY AND THE PARIS CLASSIFICATION Paris classification helps to describe the endoscopic morphology of the lesion
Used for all lesions in the GI tract
Can confer a degree of lesion severity
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JAPANESE ENDOSCOPIC CRITERIA FOR EARLY GASTRIC CANCER Dependent on Size of lesion Presence of demarcation line Presence of microvascular distortion or microsurface distortion
Difficult to determine without magnifying endoscopy
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ENDOSCOPIC SUBMUCOSAL DISSECTION
En bloc removal of gastric lesions >10mm
Beneficial for those lesions with superficial dysplasia
Dissection is down to muscle layer Can assess submucosal invasion
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JAPANESE EXTENDED CRITERIA FOR ESD
Ngamruengphong S., Abe S, Oda I Surg Clin N Am 2017; 97(2): 371-385
A – absolute indication for ESD E – extended criteria of ESD X – ESD not recommended
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WHAT TO DO TO DETECT PREMALIGNANT LESIONS Use Paris classification
Accurately report size and location
High index of suspicion for small lesions in the setting of Chronic gastritis Atrophic gastritis Intestinal metaplasia
Biopsy any suspicious areas
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CONCLUSION
Gastric cancer classification remains incomplete general categories well established
Precursor lesions can be identified as potential risks for development of adenocarcinoma
A standardized report with photos/videos is essential for subsequent management