Digestive EndoscopyGastric cancer missed at esophagogastroduodenoscopy in a well-defined Spanish population
Introduction
Gastric cancer (GC) has the sixth highest incident and fatality rates in Spain [1]. The overall 5-year survival is less than 30% because of the advanced stage at diagnosis [[2], [3], [4]].
The most common GCs are adenocarcinomas (>90%), which are the final consequence of premalignant changes such as atrophy, intestinal metaplasia, and dysplasia [5,6]. The evolution from an early to advanced stage may take about 2–3 years [7]. These premalignant changes and the speed of duplication are an opportunity for early detection of GC [8].
Esophagogastroduodenoscopy (EGD) is the standard procedure for detection and diagnosis of GC [9].
Despite efforts to improve GC detection in its early stages, a significant number of cases are not detected in an EGD [10,11]. Previous reports from Western countries indicate that between 4.6% and 14.4% of GCs had a prior negative EGD for GC in the previous 3 years [[10], [11], [12], [13], [14], [15], [16], [17]]. This problem is attributed to several factors, most of them related to technical variables such as rapid exploration, insufficient cleaning of the gastric mucosa, inability to recognize subtle early gastric lesions, or inadequate protocol of biopsies [[10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20]]. To compensate these limitations, clinical guidelines with quality indicators for the performance of EGD were recently published [[21], [22], [23]].
A number of studies have investigated the GC miss rate, but none has evaluated the quality of the prior negative EGD. In addition, there are no published data from Spain. Therefore, the aim of this study was to study the frequency and characteristics of patients with GC in whom the diagnosis was missed in a prior EGD and to assess the quality of the previous EGD based on the indicators proposed by the latest clinical guidelines.
Section snippets
Materials and methods
In this retrospective observational study, all patients with proven gastric adenocarcinoma diagnosed with endoscopic biopsies at the Pathology Unit of Hospital General de Granollers between January 2012 and December 2016 were reviewed. We excluded patients in whom the prior EGDs were incomplete, had a suspicion for malignancy that was not confirmed with biopsies, and those enrolled in a cancer surveillance program (dysplasia or peptic gastric ulcer detected 3 months before and patients with a
Results
A total of 212 GC cases were identified during the 5-year study period; 25 patients were excluded, leaving a total of 187 patients included for the analysis (Fig. 1). Seventeen out of 187 patients had a prior negative EGD within 3 years of the diagnosis of GC (miss rate: 9.1%). Demographic and clinical data of patients with and without missed GC showed no difference (Table 1).
Twelve out of 17 missed GCs had some abnormality in the prior EGD and in 6 of them, biopsies were taken (only in 3 cases
Discussion
This is the first study that evaluates the missed rate of GC in Spain in a cohort of patients with symptoms and shows that it is one of the lowest reported in Western countries. Most importantly, a significant proportion of patients with GC were misdiagnosed at the first endoscopy because of a variety of errors made by the endoscopists, including misinterpretation of some findings, detecting an abnormality but not taking a biopsy, taking an insufficient number of biopsies, and lack of follow-up.
Conclusion
The proportion of missed GC in an EGD in Spain is not uncommon but is one of the lowest reported in a Western country. On the basis of our results, the endoscopist is an important factor for missed cancer (lack of lesion recognition and sampling error), and efforts must be made to achieve an adequate proficiency. Compliance with quality indicators, including a more rigorous protocol of biopsies and repeat endoscopy must be implemented to reduce the number of missed GC at the initial endoscopy.
Conflict of interest
None declared.
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