1. A SYSTEMATIC REVIEW OF THE VALIDITY OF ENDOSCOPIC ULTRASOUND FOR GASTRIC CARCINOMA STAGING Turma 15 Supervisors Prof. Doutor Altamiro da Costa Pereira Prof. Doutor Mário Dinis Ribeiro Serviço de Bioestatísca e Informática Médica Faculdade de Medicina da Universidade do Porto 2005/2006

2. BACKGROUND Gastric Cancer Gastric carcinoma is one of the most common malignancies throughout the world, although its incidence has decreased over the past decades. After liver, colon and breast cancer is the fourth most common malignant disease. Tseng, LJ, et al, Hep-gastro, 2000, 47:897-900 Early detection and diagnosis are crucial for a successful treatment. Clinical staging of gastric cancer is important in designing the strategy of treatment. Sandhu IS, et al.; Medclin N Am 86; 2002; 1289-1317 Validity of EUS in Gastric Cancer

3. BACKGROUND Endoscopic Ultrasound (EUS) Endoscopic Ultrasound (EUS) combines endoscopy and ultrasound in order to obtain images and information about the digestive tract and the surrounding tissue and organs Sandhu IS, et al.; Medclin N Am 86; 2002; 1289-1317 It may be used for preoperative staging of gastric cancer, but performance values given in the literature differ Kelly et al, Gut,2001 Oct; 49 (4): 534-9 The system most often used to stage stomach cancer is TNM system Validity of EUS in Gastric Cancer

4. BACKGROUND Primary Aim: To evaluate the validity and consistency of endoscopic ultrasound in diagnosis of gastric cancer staging. Validity of EUS in Gastric Cancer

5. MATERIAL AND METHODS Study Design Systematic Review Validity of EUS in Gastric Cancer

6. MATERIAL AND METHODS Data search: Query (((((((((((sensitivity and specificity OR sensitivity and specificity/standards) OR specificity) OR screening) OR false positive) OR false negative) OR accuracy) OR ((((predictive value OR predictive value of tests) OR predictive value of tests/standards) OR predictive values) OR predictive values of tests)) OR ((reference value OR reference values) OR reference values/standards)) OR (((((((((((roc OR roc analyses) OR roc analysis) OR roc and OR roc area) OR roc auc) OR roc characteristics) OR roc curve) OR roc curve method) OR roc curves) OR roc estimated) OR roc evaluation)) OR likelihood ratio) AND human) Field: All Fields, Limits: 10 Years, Humans, MEDLINE AND"Endosonography"[MeSH]AND ("Stomach Neoplasms"[MeSH] AND "Neoplasm Staging"[MeSH]) NOT "Lymphoma"[MeSH] Devillé et al, BMC Medical Research Methodology, 2002; 2:9 Validity of EUS in Gastric Cancer

7. MATERIAL AND METHODS Inclusion Criteria Studies of validity of EUS versus surgical specimens in patients with gastric carcinoma (GOLD STANDARD) Language (english, french and spanish) Validity of EUS in Gastric Cancer

8. MATERIAL AND METHODS Exclusion Criteria Impossibility of constructing a 2x2 table No reference to the TNM classification Papers unavailable on the Internet or at FMUP or IPO libraries Abstract unavailable on Medline or Scopus Validity of EUS in Gastric Cancer

9. MATERIAL AND METHODS Flow Chart with Methods Validity of EUS in Gastric Cancer

11. MATERIAL AND METHODS Article’s Quality Validity of EUS in Gastric Cancer

12. Bossuyt et al, Ann Intern Med, 2003; 138: 40-44

13. MATERIAL AND METHODS Data Extracted Year of procedure Patients in study Quality criteria Relation between gold standard and EUS diagnosis for T and N staging (true positives, true negatives, false positives, false negatives), in different thresholds Instrument - Brand - Frequency Operator (single vs several) Validity of EUS in Gastric Cancer Data Base

14. MATERIAL AND METHODS Statistical Analysis Sensitivity - Proportion of ill individuals whose test is positive Specificity - Proportion of not ill individuals whose test is negative Validity of EUS in Gastric Cancer

15. RESULTS Articles Description Article’s number

16. RESULTS Articles Description Total number of patients of the study Median 114 Minimum 22 Maximum 1120 Validity of EUS in Gastric Cancer

17. RESULTS Articles Description Quality assessment Results of stard table

18. RESULTS Validity of EUS in Gastric Cancer Articles Description

19. RESULTS Validity of EUS in Gastric Cancer Results for T staging Sensitivity – T1 vs T2 T3 T4

20. RESULTS Validity of EUS in Gastric Cancer Results for T staging Specificity – T1 vs T2 T3 T4

21. RESULTS Validity of EUS in Gastric Cancer Results for T staging SROC – T1 vs T2 T3 T4

22. RESULTS Validity of EUS in Gastric Cancer Results for T staging Sensitivity – T1 T2 vs T3 T4

23. RESULTS Validity of EUS in Gastric Cancer Results for T staging Specificity – T1 T2 vs T3 T4

24. RESULTS Validity of EUS in Gastric Cancer Results for T staging SROC – T1 T2 vs T3 T4

25. RESULTS Validity of EUS in Gastric Cancer Results for T staging Sensitivity – T1 T2 T3 vs T4

26. RESULTS Validity of EUS in Gastric Cancer Results for T staging Specificity – T1 T2 T3 vs T4

27. RESULTS Validity of EUS in Gastric Cancer Results for T staging SROC – T1 T2 T3 vs T4

28. RESULTS Validity of EUS in Gastric Cancer Results for N staging Sensitivity – N0 vs N+

29. RESULTS Validity of EUS in Gastric Cancer Results for N staging Specificity – N0 vs N+

30. RESULTS Validity of EUS in Gastric Cancer Results for N staging SROC – N0 vs N+

31. DISCUSSION Comparison between all thresholds: Validity of EUS in Gastric Cancer

32. DISCUSSION

33. DISCUSSION

34. DISCUSSION The first threshold (T1 vs T2 T3 T4) has the best sensitivity. Specificity has the best results in the third threshold (T1 T2 T3 vs T4).  EUS is a reliable method to detect the stages T1 vs T2 and T3 vs T4. Validity of EUS in Gastric Cancer

35. DISCUSSION Sensitivity and specificity were higher for T staging than for N staging Sensitivity and specificity were higher for T staging than for N staging  EUS is a better diagnosis method for determination of the tumour penetration depth (T staging) than for lymphatic nodes invasion (N staging) Validity of EUS in Gastric Cancer

36. DISCUSSION Comparison with literature: The very limited penetration depth of early tumors can be clearly displayed and reliably determined on EUS scanning Together with reports elsewhere, it is accepted that EUS is an accurate staging modality in most cases, with a few exceptions of overstaging and understaging. WD, et al, World J Grastroent, 2003;9(2):254-257 Validity of EUS in Gastric Cancer

37. STUDY LIMITATIONS Bibliographic research restricted to Medline and Scopus Lack of information regarding to methodological procedures, in the papers Inclusion and exclusion criteria Language restrictions Abstract unavailable on Medline and Scopus Validity of EUS in Gastric Cancer

38. GANTT’S MAP Validity of EUS in Gastric Cancer Gantt’s Map

39. REFERENCES Bossuyt PM, Reitsma JB, Bruns DE, Gatsonis CA, Glasziou PP, Irwing LM, et al. Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD iniative. Ann Intern Med. 2003 Jan 7; 138: 40-44. Devillé WL, Buntinx F, Boputer LM, Montori VM, de Vet HCW, van der Windt DAWM, et al. Conducting systematic reviews of diagnostic studies: didactic guidelines. BMC Medical Research Methodology. 2002; 2: 9. Kelly S, Harris KM, Berry E, Hutton J, Roderick P, Cullingworth J, et al. A systematic review of the staging performance of endoscopic ultrasound in gastro-oesophageal carcinoma. Gut. 2001 Oct; 49(4): 534-9. Cited in PubMed; PMID 11559651. Tseng, LJ, Lin- Ray MD, Thian-Lok MD, et al. Video- Endoscopic Ultrasound in staging gastric carcinoma. Hepato- Gastroenterology 200; 47:897- 900. Sandhu IS, Manoop S, Bhutani, MD. Gastrointestinal endoscopic ultrasonography. Medclin N Am 86. 2002; 1289 – 1317. Validity of EUS in Gastric Cancer