Carcinoma stomach

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carcinoma stomach
associated with epigastric mass moving with respiration,
history, symptoms
examination , clinical findings
staging, differential diagnosis
treatment, surgical options, subtotal gastrectomy, total gastrectomy,
radiothyerapy, chemotherapy

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Carcinoma stomach

  1. 1. Case Presentation By Dr Saleem
  2. 2. Scenario <ul><li>50 years male with mass epigastrium moving with respiration, associated with vomiting, wt loss for two months </li></ul><ul><li>O/E : Left supraclavicular node palpable </li></ul>
  3. 3. Provisional Diagnosis <ul><li>Ca Stomach </li></ul>
  4. 4. Differential Diagnosis <ul><li>Ca transverse colon </li></ul><ul><li>Ca lt lobe of liver </li></ul><ul><li>Ca gall bladder </li></ul>
  5. 5. History <ul><li>Age 50 years </li></ul><ul><li>Sex Male </li></ul><ul><li>Duration 02 months </li></ul><ul><li>Nausea vomiting </li></ul>
  6. 6. History <ul><li>Epigastric Discomfort,Dyspepsia </li></ul><ul><li>Dysphagia </li></ul><ul><li>Wt loss </li></ul><ul><li>anorexia and early satiety </li></ul>
  7. 7. Contd: <ul><li>Haemetemesis </li></ul><ul><li>Malena </li></ul><ul><li>Altered Bowel habbits </li></ul><ul><li>Bleeding P/R </li></ul>
  8. 8. Contd: <ul><li>Shortness of breath </li></ul><ul><li>Juandice </li></ul><ul><li>Smoking </li></ul><ul><li>Past history </li></ul><ul><li>Family history </li></ul>
  9. 9. Physical Findings <ul><li>GPE </li></ul><ul><li>Pallor </li></ul><ul><li>Lymph nodes </li></ul><ul><li>Lt Supraclavicular (virchow) </li></ul><ul><li>Ant Axillary (irish nodes) </li></ul><ul><li>Cervical lymph nodes </li></ul>
  10. 11. Contd: <ul><li>Trousseau,s sign </li></ul><ul><li>Thrombophelbitis </li></ul><ul><li>Acanthosis Nigricanus </li></ul><ul><li>Hyperpigmentation </li></ul>
  11. 12. Abdomen <ul><li>Mass epigastrium </li></ul><ul><li>moves with respiration </li></ul><ul><li>hard </li></ul><ul><li>non tender </li></ul><ul><li>irregular </li></ul><ul><li>seperate from liver </li></ul><ul><li>succussion splash </li></ul>
  12. 13. Contd: <ul><li>Periumblical metastasis </li></ul><ul><li>Sister Mary Joseph </li></ul><ul><li>nodule </li></ul><ul><li>Hepatomegaly </li></ul><ul><li>Pelvic Masses (Krukenberg tumor) </li></ul><ul><li>Ascites </li></ul><ul><li>Plueral effusion </li></ul>
  13. 14. Title <ul><li>DRE </li></ul><ul><li>Blumer shelf </li></ul><ul><li>Hard nodularity extraluminaly and </li></ul><ul><li>anteriorly </li></ul><ul><li>also called ,Drop metastasis: </li></ul>
  14. 15. Investigations <ul><li>Baseline </li></ul><ul><li>Goal to assist for optimal therapy </li></ul><ul><li>CBC </li></ul><ul><li>LFT,s </li></ul><ul><li>Stool for occult blood </li></ul>
  15. 16. Diagnostic workup <ul><li>Upper GI endoscopy </li></ul><ul><li>95 % accuracy </li></ul><ul><li>Tissue diagnosis </li></ul><ul><li>Ulcerated lesion (take 6 biopsies around the </li></ul><ul><li>lesion) </li></ul>
  16. 17. Contd: <ul><li>Double contrast upper GI series </li></ul><ul><li>And Barium swallow </li></ul><ul><li>75% accuracy </li></ul><ul><li>for obstructive lesions only </li></ul>
  17. 20. Staging Investigations <ul><li>Endoluminal U/S </li></ul><ul><li>Accuracy for tumor penetration </li></ul><ul><li>involvement of adjacent structures </li></ul><ul><li>Lymph nodes involvement </li></ul><ul><li>Operater dependent </li></ul>
  18. 21. Contd: <ul><li>Chest X ray </li></ul><ul><li>lung mets </li></ul><ul><li>plurel effusion </li></ul><ul><li>U/S abdomen </li></ul><ul><li>liver mets </li></ul>
  19. 22. Contd: <ul><li>CT scan Abdomen and Pelvis </li></ul><ul><li>loccaly advanced disease </li></ul><ul><li>Metastasis </li></ul><ul><li>Extra regional lymphadenopathy </li></ul><ul><li>PET Scan </li></ul><ul><li>To determine sites of unexpected metastasis </li></ul>
  20. 25. Contd: <ul><li>Staging Laproscopy </li></ul><ul><li>To determine possibilty of curitive lesion </li></ul><ul><li>look for peritoneal and hepatic mets </li></ul>
  21. 26. Staging <ul><li>Primary tumor </li></ul><ul><li>Tx- cannot be assessed </li></ul><ul><li>T0- no evidence </li></ul><ul><li>Tis- carcinoma in situ, no invasion of lamina </li></ul><ul><li>T1- invades lamina propria or submucosa </li></ul><ul><li>T2- invades muscularis or subserosa </li></ul><ul><li>T3- penetrates serosa, no adjacent structure </li></ul><ul><li>T4- invades adjacent structures </li></ul>
  22. 27. Regional lymph nodes <ul><li>NX- cannot be assessed </li></ul><ul><li>N0- no nodes </li></ul><ul><li>N1- mets in 1-6 regional nodes </li></ul><ul><li>N2- mets in 7-15 regional nodes </li></ul><ul><li>N3- mets in more than 15 regional nodes </li></ul>
  23. 28. Distant Metastasis <ul><li>MX- cannot be assessed </li></ul><ul><li>M0- no distant metastases </li></ul><ul><li>M1-distant metastases </li></ul>
  24. 29. Stages <ul><li>* Stage 0 - Tis, N0, M0 </li></ul><ul><li>* Stage IA - T1, N0 or N1, M0 </li></ul><ul><li>* Stage IB - T1, N2, M0 or T2a/b, N0, M0 </li></ul><ul><li>* Stage II - T1, N2, M0 or T2a/b, N1, M0 or T2, N0, M0 </li></ul><ul><li>* Stage IIIA - T2a/b, N2, M0 or T3, N1, M0 or T4, N0, M0 </li></ul><ul><li>* Stage IIIB - T3, N2, M0 </li></ul><ul><li>* Stage IV - T1-3, N3, M0 or T4, N1-3, M0, or any T, any N, M1 </li></ul>
  25. 30. Title <ul><li>Stage 4 </li></ul>
  26. 31. Title
  27. 32. Treatment <ul><li>Surgery is the only curative treatment for gastric cancer. </li></ul><ul><li>It is the best palliation </li></ul><ul><li>provides the most accurate staging. </li></ul>
  28. 33. Exceptions <ul><li>patients who cannot tolerate an abdominal operation, and </li></ul><ul><li>patients with overwhelming metastatic disease. </li></ul>
  29. 34. Goal of Treatment <ul><li>resection of all tumor </li></ul><ul><li>all margins (proximal, distal, and radial) should be negative and an adequate lymphadenectomy performed </li></ul><ul><li>negative margin of at least 5 cm </li></ul>
  30. 35. Subtotal gastrectomy <ul><li>standard operation for gastric cancer is radical subtotal gastrectomy </li></ul>
  31. 36. Lower radical partial gastrectomy <ul><li>carcinoma of the lower third of the stomach. </li></ul><ul><li>ligation of the left and right gastric and gastroepiploic arteries at the origin </li></ul><ul><li>en bloc removal of the distal 75% of the stomach, including the pylorus and 2 cm of duodenum </li></ul><ul><li>the greater and lesser omentum, and all associated lymphatic tissue </li></ul>
  32. 38. Reconstruction <ul><li>Reconstruction is usually by Billroth II gastrojejunostomy, </li></ul><ul><li>if a small gastric remnant is left (<20%), a Roux-en-Y reconstruction is considered. </li></ul>
  33. 41. Esophagogasrectomy <ul><li>growth involving the cardia and gastroesophageal junction </li></ul>
  34. 42. Upper radical partial gastrectomy <ul><li>Growths of upper third </li></ul><ul><li>Reconstruction </li></ul><ul><li>esophagogastrostomy </li></ul><ul><li>Pyloroplasty </li></ul><ul><li>An isoperistaltic jejunal interposition (Henley loop) between the esophagus and antrum could be considered. </li></ul>
  35. 43. Total Gastrectomy <ul><li>Survival similar compared with subtotal gastrectomy </li></ul><ul><li>Complications higher </li></ul><ul><li>Total gastrectomy with jejunal pouch/ esophageal anastomosis may be the best operation for patients with proximal gastric adenocarcinoma ,linitis plastica </li></ul>
  36. 44. Reconstruction
  37. 45. Lymphadenectomy <ul><li>The extent of resection is described as </li></ul><ul><li>D1. Limited Lymphadenectomy. All N1 Nodes removed en bloc with the stomach </li></ul><ul><li>D2. Systematic Lymphadenectomy. N1 & N2 nodes en bloc with stomach </li></ul><ul><li>D3. Extended Lymphadenectomy. A more radical en bloc resection including N3 nodes </li></ul>
  38. 47. Extent of lymphadenectomy <ul><li>Two randomized trials compared D1 with D2 lymphadenectomy in patients who were treated for curative intent. </li></ul><ul><li>postoperative morbidity (43% versus 25%) and mortality (10% versus 4%) were higher in the D2 group. </li></ul><ul><li>Drawback </li></ul>
  39. 48. Recommended <ul><li>A pancreas and spleen-preserving D2 lymphadenectomy </li></ul>
  40. 49. Carcinoma upper third
  41. 50. Carcinoma middle third
  42. 51. Carcinoma lower third
  43. 52. Post op complications <ul><li>Early complications </li></ul><ul><li>Paralytic ileus. </li></ul><ul><li>Leakage from suture line. </li></ul><ul><li>Leakage from duodenal stump. </li></ul><ul><li>Acute Cholycystitis, Pancreatitis </li></ul><ul><li>Stomal obstruction. </li></ul>
  44. 53. Title <ul><li>Late complications </li></ul><ul><li>Early Dumping syndrome </li></ul><ul><li>Late dumping syndrome. </li></ul><ul><li>Bilious vomiting. </li></ul><ul><li>Gastric stump cancer </li></ul><ul><li>Vit B12 deficiency </li></ul><ul><li>Osteoporosis </li></ul>
  45. 54. Adjuvant Therapy <ul><li>Rationale behind radiotherapy is to provide additional local-regional tumor control. </li></ul><ul><li>Adjuvant chemotherapy is used either as a radiosensitizer or as definitive treatment for presumed systemic metastases. </li></ul>
  46. 55. Adjuvant Radiotherapy <ul><li>lower rates of local recurrence in patients who received postoperative radiotherapy than in those who underwent surgery alone </li></ul><ul><li>(British stomach cancer study group) </li></ul><ul><li>Improved survival </li></ul><ul><li>(mayo clinic randomized patients) </li></ul>
  47. 56. Intra operative radiotherapy <ul><li>allows for a high dose to be given in a single fraction while in the operating room so that other critical structures can be avoided.  </li></ul><ul><li>Stage 3 and 4 </li></ul><ul><li>Median survival (21 months vs 10 months ) with IORT </li></ul>
  48. 57. Adjuvant Chemotherapy <ul><li>No consistent survival benefit. </li></ul><ul><li>Epirubicin . 5 florouracil ,cis platinium (ECF) </li></ul><ul><li>Combination of chemoradio therapy has better outcome </li></ul>
  49. 58. Neo adjuvant chemotherapy <ul><li>downstaging of disease to increase resectability, </li></ul><ul><li>decrease micrometastatic disease burden prior to surgery </li></ul><ul><li>allow patient tolerability prior to surgery </li></ul><ul><li>determine chemotherapy sensitivity </li></ul><ul><li>reduce the rate of local and distant recurrences, and ultimately improve survival. </li></ul>
  50. 59. Palliative Care <ul><li>radiotherapy provides relief from bleeding, obstruction, and pain in 50-75% </li></ul><ul><li>wide local excision, partial gastrectomy, total gastrectomy, simple laparotomy, gastrointestinal anastomosis, and bypass for food intake or pain relief </li></ul>
  51. 60. Summary
  52. 61. Thankyou

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