4. Gastrointestinal Tract Cancer in Europe

MATATOSHI DOHMOTO

1. Introduction

In this chapter the clinical differences in the diagnosis and endoscopic treatment of gastrointestinal tract carcinoma between Europe and Japan are reviewed.

There is a still little interest in early gastric cancer in Europe today because the frequency is low. Therefore, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) methods have not yet become common. So-called EMR methods such as snare EMR, EAM (endoscopic aspiration mucosectomy) and EMR-L (endoscopic mucosal resection using ligation device) as well as associated instruments such as flex [1], hook [2], insulated tip (IT) [3], and triangleknife [4] are not yet well known.

There is little detection of early cancer in Europe due to the fact that the incidence of gastric cancer is low, and screening examinations for gastric cancer detection are not widespread (Soehendra N, Grund KE, personal communications, 2005). Therefore this field of study is not so active in Europe, and diagnosis of early cancer and endoscopic treatment are not considered paramount.

A suspicious finding on radiological examination necessitates an endoscopic biopsy in any case. X-ray detection of early gastric cancer is not common, however, in consideration of radiation exposure to the X-rays.

On average, 3–9 cases of early gastric cancer per year were diagnosed in five hospitals in Germany and Austria where EMR was performed (Grund KE, Tuebingen; Kaehler GFBA, Mannheim; Hagenmueller

F, Hamburg-Altona; Heinermann PM, Salzburg;

Soehendra N, Hamburg, personal communications, 2005). The average mortality for gastric cancer (1995– 2000) of the 16 developed countries in Europe is very low (12.2 per 100 000 population, compared with Japan, 39.8/100 000) (Ministry of Health in Japan, Labor and Welfare 2001). This might be the main reason the number of diagnoses and use of endoscopic treatment for early gastric cancer have not increased in Europe.

According to recent research carried out in Japan, most (90%) early cancers are less than 3 cm [5] and the probability of lymph node metastasis of early gastric cancer is 3% for intramucosal carcinoma and 20% for submucous carcinoma [6].

As mentioned elsewhere in this book, the Japanese Gastric Cancer Association proposes indications for en bloc resection by EMR for patients with a low risk of lymph node metastasis as summarized in Table 1. However, there are some of examples of EMR and ESD for early cancers of more than 2 cm [7–9] and for undifferentiated carcinoma [3, 10], which have been reported from Japan. An EMR of an esophageal tumor of 45 mm [11], colorectal tumors larger than 45 mm [12, 13] and a large gastric tumor (130 mm) [14] have also been reported.

2. Diagnosis

A cancer checkup of the digestive tract is rarely paid for by health insurance in Europe. Payment of endo- scopic—and X-ray—examinations of a patient without symptoms is difficult. For men older than 50 years in Austria, endoscopic examination is possible once every 5 years (Heinermann PM, personal communication, 2004).

In European hospitals routine chromoscopy, and magnification endoscopy as a routine is still limited [15]. Magnification endoscopy is not yet performed routinely in Japan either.

X-ray examination of the colon and colonoscopy have been done frequently since the advent of the hemo-occult test. Thereby colorectal tumors can be detected at an early stage with consequent reduction in the mortality of colorectal cancer [16–18].

The incidence of colorectal cancer in a control group (856 cases, 11% stage A) was 144 per 100 000 popula- tion—years in the Nottingham area of the U.K. The median follow-up was 7.8 years. Three hundred and sixty people died from colorectal cancer in the screening group compared with 420 in the control group, i.e., a 15% reduction in cumulative colorectal cancer mortality in the screening group (odds ratio = 0.85 [95% confidence interval 0.74–0.98]) [16] .

There is a higher frequency of colon cancer in Europeans than in Japanese. The Japanese classification of gastric carcinoma is well known as an endoscopic image classification. However, only a few doctors use this classification in their findings. Whether an early cancer or an advanced cancer exists is chiefly diagnosed based on pathology.

Regarding endoscopic diagnosis, a general framework for the endoscopic classification of superficial neoplastic

Table 1. Indications for endoscopic mucosal resection according to the Japanese Gastric Cancer Association guideline [31]

Principals: Tumor with a low risk of lymph node metastasis Reasonable tumor size and location for one-piece

resection

Qualified conditions:

•Differentiated M ca.

•Less than 2 cm in size regardless of macroscopic type •Without ulcer findings

Expanded indications:

•Differentiated M ca. UL( -), no limit of tumor size •Differentiated M ca. UL( +) <3 cm

•Differentiated SM1 (<500 mm) ca. <3 cm

•Undifferentiated M ca. UL( -) <2 cm (priority to an operation)

Contraindication:

Operation indication:

Cancers not fulfilling the above conditions after histopathological diagnosis

M ca.: mucosal adenocarcinoma, UL: ulcer or ulcer scar, SM1: superficial submucosal penetration

lesions of the esophagus, stomach, and colon was suggested by the Paris Endoscopic Workshop of 2002 [19].

If specified appearances of superficial neoplastic lesions are used more generally by endoscopists, an improvement in detection rates can be expected.

3. Pathology

Gastrointestinal lesions considered to be high-grade adenoma or dysplasia by Western pathologists using the conventional Western classification are often diagnosed as carcinoma by Japanese pathologists using the Japanese group classification [20]. This may also contribute to the relatively high incidence and good prognosis of gastric carcinoma in Japan when compared with Western countries [21]. To overcome these diagnostic differences, the Padova classification [22], the Vienna classification, and a revision of the Vienna classification have recently been proposed [20]. However, the newly proposed classifications should be used with caution for biopsy specimens, as sampling error may result in an underestimation of the neoplastic grade or depth of invasion [20].

4. EMR Methods

Endoscopic aspiration mucosectomy (EAM), EMRL

(endoscopic mucosal resection using ligation device), and the snare method are the mainstream EMR techniques used Europe. Roesch et al. [23] reported endoscopic en bloc resection with IT knives.

Lambert has reported the technique of EMR with an injection into the submucosa to lift the lesion for either cup and aspiration method, or tissue incision with a needle knife [24], but EMR with a hook-knife, flexknife, IT knife, or triangle knife has as yet hardly been reported.

Seewald et al. reported piecemeal EMR by using a simple polypectomy snare without submucosal injection for Barrett’s epithelium with early-stage malignant changes. No recurrence, no serious complication, and two strictures were observed [25].

5. Discussion

Preoperative macroscopic endoscopic findings and biopsy diagnosis may lead to suspicion of early cancer. Because early cancer is defined as invasion not reaching the muscularis propria, the final diagnosis is entrusted to pathological examination of the resected lesion [26, 27]. Diagnosis by endoscopic ultrasonography is not considered to be obligatory.

In Europe the average mortality of gastric cancer among the 16 developed European countries is just 12.2 people per 100 000 population (1995–2000), whereas it is more than three times higher (39.8/100 000) in Japan (2001). This is probably the main reason why the number of diagnoses and endoscopic treatments of early gastric cancer have not increased in Europe.

In Europe it is not a common procedure to detect early cancer by a screening examination for gastric and colon cancer, which on the other hand is regularly provided to people more than 40 years old in Japan. However, in Europe circumferential EMR in Barrett’s esophagus with high-grade intraepithelial neoplasia has been reported [25, 28, 29] much more often than in Japan where a frequent cancer checkup is available. Furthermore, massive hiatus hernia and Barrett’s epithelium are observed daily on endoscopic examination in Europe (author’s personal observations).

EMR of early neoplasia in Barrett’s esophagus is carried out mainly in Europe. Excision specimens of early neoplasia in Barrett’s esophagus were pathologically inspected by Vieth et al. for submucosal invasion, lowor high-grade intraepithelial neoplasia, and infiltration of blood vessels and lymph ducts [28].

More residue and recurrences may occur after piecemeal resection than after en bloc resection [9, 30]. Therefore, the latter is preferred to the former.

In Japan, complete resection is diagnosed from an en bloc resection specimen. Because there is much piecemeal resection in Europe, complete excision is confirmed from the abscission surfaces. On the other hand, a great merit of piecemeal resection is that fewer complications arise than for en bloc excision.

Follow-up of the patient after surgery is not easy in Europe, because for postoperative observation the patient depends mainly on his general practitioner (home doctor). Without doubt the system of health insurance is partially the cause for this situation.

For the choice between endoscopic and surgical therapy, determination of the depth of infiltration by endoscopic ultrasound is essential. In contrast to a surgical operation, endoscopic methods can lower the cost of therapy as well as the rate of morbidity and mortality. However, the endoscopist must consider the possibility of residual disease and recurrence when using EMR and ESD methods for early-stage cancer.

On the whole it does not seem that EMR methods with current instruments can be considered definitive (Soehendra, personal communication, 2004). Regarding complications and suffering of the patient, it will be necessary to review the results of EMR and ESD that involve an especially long time (>1 h) and extensive resection (>5 cm).

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