GastRointestinal gndoscoPY Editor WILLIAM S. HAUBRICH, M.D. Assistant Editor ELLEN C. SHANNON, M.A. Business Manager DONALD. W. TRUMAN, A.B. Ed itor for Abstracts BERNARD M. SCHUMAN, M.D. Address all correspondence to the Editor Scripps Clinic & Research Foundation 476 Prospect Street La Jolla, California 92037
Editorial Consu Itants J. EDWARD BERK, M.D. Irvine H. WORTH BOYCE, M.D. Tampa BASIL I. HIRSCHOWITZ, M.D. Birmingham WILLIAM H. MAHOOD, M.D. Philadelphia JOHN F. MORRISSEY, M.D. Madison FRANCISCO VILARDELL, M.D. Barcelona
Advertising Committee HENRY COLCHER, M.D., Chairman 605 Commonwealth Avenue Boston, Massachusetts 02215 EUGENE A. GELZAYD, M.D. Southfield JOSEPH E. GENNEN, M.D. Racine JEROME A. ECKER, MD. Santa Barbara BERNARD M. SCHUMAN, M.D. Chairman, NS/G/E Budget and Finance Committee Detroit
VOLUME 23, NO.1, 1976
Early gastric cancer Early gastric cancer is of 2 types: the cancer in a part of an ulcer and the early superficial spreading cancer which is not ulcerated. The former is the one more familiarto European and American endoscopists and is the subject of the perennial debate between those who would operate indiscriminately on all gastric ulcers because some are malignant and those who would adopt a more conservative approach. Today endoscopy, with biopsy and brush cytology added to the generally broad experiences of most endoscopists, should make such debate redundant. With the ancillary use of cytology with biopsy, cancer in an ulcer can be diagnosed by appearance alone in 94% to 99.5% of cases. '02 If any doubt exists, the procedures should be repeated in a month. Unsuspected cancer has been found in about 6% of resected gastric ulcers.3-4 However, applying stricter criteria, even fewer ulcer-cancers would be diagnosed'; follow-up of gastric ulcers treated medically tends to support the latter view and, moreover, the beliefthatthe stomach in which a gastric ulcer occurs does not carry a greater risk of cancer in any other location either. On present evidence, removal of all ulcers because of a remote and theoretical risk of cancer is totally unjustifiable, but the possibility of an existing malignancy in an ulcer should make us work up each ulcer in a precise and systematic way. In his survey of opinion and experience among U.s. endoscopists, Dr. Morrissey has addressed himself to the second of the ways in which early gastric cancer can present: the superficial spreading cancer. In the end, this survey resolves nothing. The question, in essence, is why our endoscopists are diagnosing so few early gastric cancers compared to the diagnoses of the japanese endoscopists. The subject is unsatisfactory because it lacks a reference standard by which U.S., European, and japanese pathologists could compose their differences. One is inclined to ask whether the high incidence and the high cure rate of this early gastric cancer may not, in fact, represent a straw man. Could it be that both the endoscopists and the pathologists in japan are using marginal or very liberal criteria to diagnose malignancy? What comes to mind is the colonic epithelial atypia seen in ulcerative colitis or in colonic polyps where, with more liberal interpretation, the number of early cancers and the proportion of cancers cured by surgery could be much increased. Without review of the biopsies and histology of resected specimens, read blindly by a pathologist or panel of pathologists (including japanese), the survey remains a collection of anecdotes; the survey questionnaires asked for no verification or hard data. As pointed out by Morrissey, there are inexplicable discrepancies between experienced and inexperienced endoscopists which further underscore the lack of adequate standards. Nowhere does the report say how the diagnosis was confirmed. The number of false-positive diagnoses would have put the matter in better perspective. The accuracy of biopsy (Table IV) is another subject open to interpretation. In this case we must assume that surgery and histology of the resected stomach became the reference point, but this is never· clearly indicated. By this criterion, 16% of the early cancers so diagnosed had negative biopsies and were sent to surgery on the basis of endoscopic (or perhaps x-ray) appearance with negative biopsy. As the paper indicates, the Europeans were even more sure of their eyes. How many cancers were missed and not sent to surgery can only be 45
guessed; a Japanese reviewer would guess many more than would this reviewer. Furthermore, the whole question could be answered only by a rigorously designed and executed study with long-term follow-up. And so the polemic continues at a semantic level on how to define early gastric cancer. Dr. Morrissey would do well to address himself to that question a little more. If we could all agree on what we are talking about, a survey such as this might have some validity. As it stands, it documents either a true difference in prevalence of (early) gastric cancer or a serious difference in interpretation of histology between the United States and Japan. Thus, while the paper represents a survey of opinion and experience among U.S. endoscopists, it is little more than that. The subject and its definitions are unsatisfactory, and only adequate international prospective studies with rigidly defined criteria can answer this important question. Basil!. Hirschowitz, MD REFERENCES:
lir
r ad r
r
pond
Handy storage of endoscopic accessories Endoscopic accessories such as cytology brushes and biopsy forceps or snares are difficult to store safely and efficiently. We had unacceptable breakage and misplacement of these delicate instruments until we devised our current technique. Now, each accessory is placed in a plastic zippered pocket which inserts in a loose leaf binder (see illustration) The accessories for each different endoscope are placed
1. SEGAL AW, HEALEY M)R, Cox AG, WILLIAMS I, SLAVIN G, SMITHIES A, LEVI AJ: Diagnosis of gastric cancer. Br Med I ii:669, 1975. 2. WinE S: The results of cytology using the technique of the gastroscopic cell brush, in comparison with biopsy, endoscopy and radiology. (in Early Gastric Cancer, edited byH. Grunzeand S. Wille) p. 118, New York, 1974. 3. MONTGOMERY RD, RICHARDSON BP: Gastric ulcer and cancer. Q IN Med 44:591, 1975. 4. MASON MK: Surface carcinoma of the stomach. Gut 6:185, 1965. 5. NEWCOMB WD: The relationship between peptic ulceration and gastric carcinoma. Br I Surg 20:279, 1932.
How patients see themselves The following delightful verse, in parody of Chaucer's Canterbury Tales - as it might have been related by the pardoner - was composed by Mrs. Sylvia Slotoroff of Margate, New Jersey. Mrs. Slotoroff was inspired by her preparation for barium enema examination. - Ed.
THE PACIENT'S TALE .... 0 wombe! 0 bely! 0 stinking cod, Fulfilled of donge and corrupcioun! At either end of thee foul is the soun. .... Sour is thy breeth, foul artow to embrace. Thus spak and spitte and brayd I venim Under hewe of Fleet phisyk bre~e ful of stryving and of wreccedness in privee. Agayn bifel Barium whyt in me heigh and lowe, 0 grete humilitee!
in a separate color-coded binder and stored on an accessible shelf in the endoscopy room. When each endoscope is used, all of its accessories are readily available in its corresponding binder. This method of storing accessories has been especially helpful when the endoscopy service rushes off to a different hospital for emergency procedures or when we unexpectedly use several instruments during one examination. Doris Bergman, RN Gastrointestinal Endoscopy Service University Hospital University of Washington Seattle, Washington
now it's our turn to tell you of
our change of address on or about 15 November 1976 The Scripps Clinic & Research Foundation will move to a new facility at
10666 North Torrey Pines Road La Jolla CA 92037 This will be the new address of the editorial office . to which all correspondence should be sent. Thank you for your cooperation
46
GASTROINTESTINAL ENDOSCOPY
Editorial Consu Itants J. EDWARD BERK, M.D. Irvine H. WORTH BOYCE, M.D. Tampa BASIL I. HIRSCHOWITZ, M.D. Birmingham WILLIAM H. MAHOOD, M.D. Philadelphia JOHN F. MORRISSEY, M.D. Madison FRANCISCO VILARDELL, M.D. Barcelona
Advertising Committee HENRY COLCHER, M.D., Chairman 605 Commonwealth Avenue Boston, Massachusetts 02215 EUGENE A. GELZAYD, M.D. Southfield JOSEPH E. GENNEN, M.D. Racine JEROME A. ECKER, MD. Santa Barbara BERNARD M. SCHUMAN, M.D. Chairman, NS/G/E Budget and Finance Committee Detroit
VOLUME 23, NO.1, 1976
Early gastric cancer Early gastric cancer is of 2 types: the cancer in a part of an ulcer and the early superficial spreading cancer which is not ulcerated. The former is the one more familiarto European and American endoscopists and is the subject of the perennial debate between those who would operate indiscriminately on all gastric ulcers because some are malignant and those who would adopt a more conservative approach. Today endoscopy, with biopsy and brush cytology added to the generally broad experiences of most endoscopists, should make such debate redundant. With the ancillary use of cytology with biopsy, cancer in an ulcer can be diagnosed by appearance alone in 94% to 99.5% of cases. '02 If any doubt exists, the procedures should be repeated in a month. Unsuspected cancer has been found in about 6% of resected gastric ulcers.3-4 However, applying stricter criteria, even fewer ulcer-cancers would be diagnosed'; follow-up of gastric ulcers treated medically tends to support the latter view and, moreover, the beliefthatthe stomach in which a gastric ulcer occurs does not carry a greater risk of cancer in any other location either. On present evidence, removal of all ulcers because of a remote and theoretical risk of cancer is totally unjustifiable, but the possibility of an existing malignancy in an ulcer should make us work up each ulcer in a precise and systematic way. In his survey of opinion and experience among U.s. endoscopists, Dr. Morrissey has addressed himself to the second of the ways in which early gastric cancer can present: the superficial spreading cancer. In the end, this survey resolves nothing. The question, in essence, is why our endoscopists are diagnosing so few early gastric cancers compared to the diagnoses of the japanese endoscopists. The subject is unsatisfactory because it lacks a reference standard by which U.S., European, and japanese pathologists could compose their differences. One is inclined to ask whether the high incidence and the high cure rate of this early gastric cancer may not, in fact, represent a straw man. Could it be that both the endoscopists and the pathologists in japan are using marginal or very liberal criteria to diagnose malignancy? What comes to mind is the colonic epithelial atypia seen in ulcerative colitis or in colonic polyps where, with more liberal interpretation, the number of early cancers and the proportion of cancers cured by surgery could be much increased. Without review of the biopsies and histology of resected specimens, read blindly by a pathologist or panel of pathologists (including japanese), the survey remains a collection of anecdotes; the survey questionnaires asked for no verification or hard data. As pointed out by Morrissey, there are inexplicable discrepancies between experienced and inexperienced endoscopists which further underscore the lack of adequate standards. Nowhere does the report say how the diagnosis was confirmed. The number of false-positive diagnoses would have put the matter in better perspective. The accuracy of biopsy (Table IV) is another subject open to interpretation. In this case we must assume that surgery and histology of the resected stomach became the reference point, but this is never· clearly indicated. By this criterion, 16% of the early cancers so diagnosed had negative biopsies and were sent to surgery on the basis of endoscopic (or perhaps x-ray) appearance with negative biopsy. As the paper indicates, the Europeans were even more sure of their eyes. How many cancers were missed and not sent to surgery can only be 45
guessed; a Japanese reviewer would guess many more than would this reviewer. Furthermore, the whole question could be answered only by a rigorously designed and executed study with long-term follow-up. And so the polemic continues at a semantic level on how to define early gastric cancer. Dr. Morrissey would do well to address himself to that question a little more. If we could all agree on what we are talking about, a survey such as this might have some validity. As it stands, it documents either a true difference in prevalence of (early) gastric cancer or a serious difference in interpretation of histology between the United States and Japan. Thus, while the paper represents a survey of opinion and experience among U.S. endoscopists, it is little more than that. The subject and its definitions are unsatisfactory, and only adequate international prospective studies with rigidly defined criteria can answer this important question. Basil!. Hirschowitz, MD REFERENCES:
lir
r ad r
r
pond
Handy storage of endoscopic accessories Endoscopic accessories such as cytology brushes and biopsy forceps or snares are difficult to store safely and efficiently. We had unacceptable breakage and misplacement of these delicate instruments until we devised our current technique. Now, each accessory is placed in a plastic zippered pocket which inserts in a loose leaf binder (see illustration) The accessories for each different endoscope are placed
1. SEGAL AW, HEALEY M)R, Cox AG, WILLIAMS I, SLAVIN G, SMITHIES A, LEVI AJ: Diagnosis of gastric cancer. Br Med I ii:669, 1975. 2. WinE S: The results of cytology using the technique of the gastroscopic cell brush, in comparison with biopsy, endoscopy and radiology. (in Early Gastric Cancer, edited byH. Grunzeand S. Wille) p. 118, New York, 1974. 3. MONTGOMERY RD, RICHARDSON BP: Gastric ulcer and cancer. Q IN Med 44:591, 1975. 4. MASON MK: Surface carcinoma of the stomach. Gut 6:185, 1965. 5. NEWCOMB WD: The relationship between peptic ulceration and gastric carcinoma. Br I Surg 20:279, 1932.
How patients see themselves The following delightful verse, in parody of Chaucer's Canterbury Tales - as it might have been related by the pardoner - was composed by Mrs. Sylvia Slotoroff of Margate, New Jersey. Mrs. Slotoroff was inspired by her preparation for barium enema examination. - Ed.
THE PACIENT'S TALE .... 0 wombe! 0 bely! 0 stinking cod, Fulfilled of donge and corrupcioun! At either end of thee foul is the soun. .... Sour is thy breeth, foul artow to embrace. Thus spak and spitte and brayd I venim Under hewe of Fleet phisyk bre~e ful of stryving and of wreccedness in privee. Agayn bifel Barium whyt in me heigh and lowe, 0 grete humilitee!
in a separate color-coded binder and stored on an accessible shelf in the endoscopy room. When each endoscope is used, all of its accessories are readily available in its corresponding binder. This method of storing accessories has been especially helpful when the endoscopy service rushes off to a different hospital for emergency procedures or when we unexpectedly use several instruments during one examination. Doris Bergman, RN Gastrointestinal Endoscopy Service University Hospital University of Washington Seattle, Washington
now it's our turn to tell you of
our change of address on or about 15 November 1976 The Scripps Clinic & Research Foundation will move to a new facility at
10666 North Torrey Pines Road La Jolla CA 92037 This will be the new address of the editorial office . to which all correspondence should be sent. Thank you for your cooperation
46
GASTROINTESTINAL ENDOSCOPY
