Elsevier

Digestive and Liver Disease

Volume 51, Issue 8, August 2019, Pages 1123-1129
Digestive and Liver Disease

Digestive Endoscopy
Gastric cancer missed at esophagogastroduodenoscopy in a well-defined Spanish population

https://doi.org/10.1016/j.dld.2019.03.005Get rights and content

Abstract

Background

Although esophagogastroduodenoscopy (EGD) is the standard procedure for the diagnosis of gastric cancer (GC), some GCs are missed. There are no published data on the missed rate of GC in Spain.

Aims

To determine the frequency and characteristics of missed GCs and assess the quality of the EGD in a specific population with GC.

Methods

Records of all patients diagnosed with gastric adenocarcinoma between 2012 and 2016 in a defined geographic area were reviewed. Missed GC was defined as a case with a prior negative EGD for cancer. Quality indicators from the prior EGDs were measured.

Results

From 212 cases of GC, 25 cases were excluded. Seventeen out of 187 patients had a prior EGD (9.1%). Twelve of those 17 missed GC had a prior EGD with some abnormal findings. In 6 of them, biopsies were taken. Survival was no different between patients with missed and non-missed GC. Quality indicators that failed to meet standards were recording time, image documentation, and a protocol of biopsies.

Conclusions

Missed GC in an EGD in a defined population in Spain is not uncommon (9.1%). The endoscopist is an important factor in missed GC due to lack of adequate detection and sampling error. Compliance with performance of quality indicators could reduce missed GC.

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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