1. Dr Poonam Valand, Foundation Year Two Dr Anjan Dhar, Consultant Gastroenterologist COUNTY DURHAM AND DARLINGTON NHS FOUNDATION TRUST Early gastric cancer in the County Durham and Tees Valley Region – an audit of clinical practice

2. Introduction Oesophago-gastric cancer:  5 th most common malignancy and 4 th 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%

3. 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. Early Gastric Cancer – a comparison between the East and West

4. 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)

5. 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.

6. 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.

7. 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?

8. 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: County Durham and Darlington Foundation Trust North Tees Hospital Hartlepool Hospital James Cook University Hospital. Out of 105 patients 12 were diagnosed to have early gastric cancer based on:  patients presenting with High Grade Dysplasia to T1/T2-NO-MO staging. A 13 point proforma was created to collect data on:  clinical presentationsmoking  Alcoholfamily history  route of referral endoscopy findings,  pre and post interventional histologyother investigations,  final MDT decision survival in months.

9. 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.

10. Results

11. Symptoms at Presentation

12. Initial Endoscopy Findings

13. Pre-Op Endoscopic Histology

14. Endoscopic Mucosal Resection (EMR) ChromoendoscopyMarkingResecting Post resection 12 mth follow up Standard endoscopic view

15. 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.