Endoscopic prediction of tumor invasion depth in early gastric neoplasia: a prospective study in Peru / Predicción endoscópica de invasión tumoral en neoplasia gástrica temprana: Estudio prospectivo en Perú

Introduction: Endoscopic resection is the first option treatment of early gastric cancer with invasion to mucosa or superficial submucosa, because the risk of nodal metastasis is negligible. Then the prediction of tumor invasion is cardinal. Objectives: Determine the accuracy of endoscopic prediction for tumor invasion depth in early gastric neoplasia and define endoscopic characteristics associated with massive submucosal invasion. Materials and methods: Prospective sudy of diagnostic test validation. We included patients with early gastric neoplasias that were endoscopically or surgically resected from January 2012 to May 2016. Every lesion was looked for the presence of these features: margin elevation, central elevation, irregular surface, enlarged folds, size > 30mm and rigidity. The invasion prediction was categorized in: M-Sm1 when none feature was present, Sm2 when 2 or more features were present, and indeterminated when only one feature was present. We compared endoscopic prediction to pathological staging and determined diagnostic accuracy. Results: The global accuracy for endoscopic prediction was 98.2%. Sensitivity, specificity, positive and negative predictive values for M-Sm1 prediction were 97.6, 100, 100 y 92.8%, and for Sm2 prediction were 100, 97.6, 92.8 y 97.6%, respectively. Rigidity, irregular Surface, margin elevation and enlarged folds were associated with Sm2 invasion. Conclusions: Endoscopic prediction of tumor invasion depth in early gastric neoplasia is very accurate. The main endoscopic feature associated with Sm2 invasion is rigidity.

Introducción: La resección endoscópica constituye el tratamiento de elección del cáncer gástrico temprano con invasión a la mucosa o submucosa superficial, pues tiene riesgo casi nulo de metástasis ganglionar. Por tanto, la predicción de invasión tumorales cardinal. Objetivos: Determinar la precisión de la predicción de invasión tumoral de neoplasia gástrica temprana por endoscopía convencional y definir características endoscópicas asociadas a invasión submucosa masiva. Material y métodos: Estudio prospectivo de validación de una prueba diagnóstica. Se incluyeron todos los pacientes con neoplasias gástricas tempranas que fueron resecadas endoscópica o quirúrgicamente de enero 2012 a mayo 2016. En cada lesión se definió la presencia de las siguientes características: Elevación de márgenes, elevación central, irregularidad de la superficie, engrosamiento de pliegues, tamaño >30 mm y rigidez. La predicción de invasión se categorizó en: M-Sm1 cuando no tenía ninguna característica, Sm2 cuando tenía 2 o más características, e indeterminada cuando sólo tenía una característica. Se comparó la predicción endoscópica con el estadiaje patológico de los especímenes y se determinó su precisión diagnóstica. Resultados: La precisión global de la predicción endoscópica fue de 98,2%. La sensibilidad, especificidad, VPP y VPN para la predicción M-Sm1 fue 97,6, 100, 100 y 92,8%, y para la predicción Sm2 fue 100, 97,6, 92,8 y 97,6%, respectivamente. La rigidez, irregularidad en la superficie, elevación de los márgenes y engrosamiento de pliegues, se asociaron significativamente con invasión Sm2. Conclusiones: La predicción endoscópica de invasión tumoral en neoplasia gástrica temprana es muy precisa. La principal característica endoscópica asociada a invasión Sm2 es la rigidez.

Therapeutic Decision-Making Using Endoscopic Ultrasonography in Endoscopic Treatment of Early Gastric Cancer

BACKGROUND/AIMS: We evaluated the effectiveness of an endoscopic ultrasonography (EUS)-based treatment plan compared to an endoscopy-based treatment plan in selecting candidates with early gastric cancer (EGC) for endoscopic submucosal dissection based on the prediction of invasion depth. METHODS: We reviewed 393 EGCs with differentiated histology from 380 patients who underwent EUS from July 2007 to April 2010. The effectiveness of the EUS-based and endoscopy-based plans was evaluated using a simplified hypothetical treatment algorithm. RESULTS: The numbers of endoscopically determined mucosal, indeterminate, and submucosal cancers were 253 (64.4%), 56 (14.2%), and 84 (21.4%), respectively. Overall, the appropriate treatment selection rates were 75.3% (296/393) in the endoscopy-based plan and 71.5% (281/393) in the EUS-based plan (p=0.184). For endoscopic mucosal cancers, the appropriate treatment selection rates in the endoscopy-based plan were 88.1% (223/253), while the use of an EUS-based plan significantly decreased this rate to 81.4% (206/253) (p=0.036). For endoscopic submucosal cancers, the appropriate selection rates did not differ between the endoscopy-based plan (46.4%, 39/84) and the EUS-based plan (53.6%, 45/84) (p=0.070). CONCLUSIONS: EUS did not increase the likelihood of selecting the appropriate treatment in differentiated-type EGC. Therefore, EUS may not be necessary before treating differentiated-type EGC, especially in endoscopically presumed mucosal cancers.

Obstrução duodenal por mucosa gástrica heterotópica / Duodenal obstruction for heterotopic gastric mucosa

A mucosa gástrica heterotópica (MGH) é uma entidade rara, com malignização incomum, descrita em todo o trato gastrointestinal e fora dele. O relato é de uma mulher de 37 anos, com queixa de dor epigástrica associada a vômitos pós-prandiais com três meses de evolução, causado por MGH localizada na quarta porção duodenal. Submetida à ressecção do seguimento acometido, encontra-se em acompanhamento sem queixas ou sinais de recidiva. A MGH deve ser lembrada como um diagnóstico diferencial nos sangramentos e obstruções duodenais; a ressecção endoscópica ou cirúrgica, se factível, deve ser realizada com o intuito terapêutico.

The heterotopic gastric mucosa (HGM) is a rare event, with uncommon malignant, described throughout the gastrointestinal tract and beyond. The report is about a 37 years-old female, with epigastric pain associated with postprandial vomiting with three months of evolution, caused by HGM located in the fourth portion of the duodenum. The patient underwent resection of the affected segment and since then there has been no complaints or signs of recurrence. The HGM should be remembered as a differential diagnosis in bleeding and duodenal obstruction. The endoscopic or surgical resection, if feasible, should be performed with therapeutic purposes.