Case Presentation By Dr Saleem

Scenario 50 years male with mass epigastrium moving with respiration, associated with vomiting, wt loss for two months O/E : Left supraclavicular node palpable

50 years male with mass epigastrium moving with respiration, associated with vomiting, wt loss for two months

O/E : Left supraclavicular node palpable

Provisional Diagnosis Ca Stomach

Ca Stomach

Differential Diagnosis Ca transverse colon Ca lt lobe of liver Ca gall bladder

Ca transverse colon

Ca lt lobe of liver

Ca gall bladder

History Age 50 years Sex Male Duration 02 months Nausea vomiting

Age 50 years

Sex Male

Duration 02 months

Nausea vomiting

History Epigastric Discomfort,Dyspepsia Dysphagia Wt loss anorexia and early satiety

Epigastric Discomfort,Dyspepsia

Dysphagia

Wt loss

anorexia and early satiety

Contd: Haemetemesis Malena Altered Bowel habbits Bleeding P/R

Haemetemesis

Malena

Altered Bowel habbits

Bleeding P/R

Contd: Shortness of breath Juandice Smoking Past history Family history

Shortness of breath

Juandice

Smoking

Past history

Family history

Physical Findings GPE Pallor Lymph nodes Lt Supraclavicular (virchow) Ant Axillary (irish nodes) Cervical lymph nodes

GPE

Pallor

Lymph nodes

Lt Supraclavicular (virchow)

Ant Axillary (irish nodes)

Cervical lymph nodes

Contd: Trousseau,s sign Thrombophelbitis Acanthosis Nigricanus Hyperpigmentation

Trousseau,s sign

Thrombophelbitis

Acanthosis Nigricanus

Hyperpigmentation

Abdomen Mass epigastrium moves with respiration hard non tender irregular seperate from liver succussion splash

Mass epigastrium

moves with respiration

hard

non tender

irregular

seperate from liver

succussion splash

Contd: Periumblical metastasis Sister Mary Joseph nodule Hepatomegaly Pelvic Masses (Krukenberg tumor) Ascites Plueral effusion

Periumblical metastasis

Sister Mary Joseph

nodule

Hepatomegaly

Pelvic Masses (Krukenberg tumor)

Ascites

Plueral effusion

Title DRE Blumer shelf Hard nodularity extraluminaly and anteriorly also called ,Drop metastasis:

DRE

Blumer shelf

Hard nodularity extraluminaly and

anteriorly

also called ,Drop metastasis:

Investigations Baseline Goal to assist for optimal therapy CBC LFT,s Stool for occult blood

Baseline

Goal to assist for optimal therapy

CBC

LFT,s

Stool for occult blood

Diagnostic workup Upper GI endoscopy 95 % accuracy Tissue diagnosis Ulcerated lesion (take 6 biopsies around the lesion)

Upper GI endoscopy

95 % accuracy

Tissue diagnosis

Ulcerated lesion (take 6 biopsies around the

lesion)

Contd: Double contrast upper GI series And Barium swallow 75% accuracy for obstructive lesions only

Double contrast upper GI series

And Barium swallow

75% accuracy

for obstructive lesions only

Staging Investigations Endoluminal U/S Accuracy for tumor penetration involvement of adjacent structures Lymph nodes involvement Operater dependent

Endoluminal U/S

Accuracy for tumor penetration

involvement of adjacent structures

Lymph nodes involvement

Operater dependent

Contd: Chest X ray lung mets plurel effusion U/S abdomen liver mets

Chest X ray

lung mets

plurel effusion

U/S abdomen

liver mets

Contd: CT scan Abdomen and Pelvis loccaly advanced disease Metastasis Extra regional lymphadenopathy PET Scan To determine sites of unexpected metastasis

CT scan Abdomen and Pelvis

loccaly advanced disease

Metastasis

Extra regional lymphadenopathy

PET Scan

To determine sites of unexpected metastasis

Contd: Staging Laproscopy To determine possibilty of curitive lesion look for peritoneal and hepatic mets

Staging Laproscopy

To determine possibilty of curitive lesion

look for peritoneal and hepatic mets

Staging Primary tumor Tx- cannot be assessed T0- no evidence Tis- carcinoma in situ, no invasion of lamina T1- invades lamina propria or submucosa T2- invades muscularis or subserosa T3- penetrates serosa, no adjacent structure T4- invades adjacent structures

Primary tumor

Tx- cannot be assessed

T0- no evidence

Tis- carcinoma in situ, no invasion of lamina

T1- invades lamina propria or submucosa

T2- invades muscularis or subserosa

T3- penetrates serosa, no adjacent structure

T4- invades adjacent structures

Regional lymph nodes NX- cannot be assessed N0- no nodes N1- mets in 1-6 regional nodes N2- mets in 7-15 regional nodes N3- mets in more than 15 regional nodes

NX- cannot be assessed

N0- no nodes

N1- mets in 1-6 regional nodes

N2- mets in 7-15 regional nodes

N3- mets in more than 15 regional nodes

Distant Metastasis MX- cannot be assessed M0- no distant metastases M1-distant metastases

MX- cannot be assessed

M0- no distant metastases

M1-distant metastases

Stages * Stage 0 - Tis, N0, M0 * Stage IA - T1, N0 or N1, M0 * Stage IB - T1, N2, M0 or T2a/b, N0, M0 * Stage II - T1, N2, M0 or T2a/b, N1, M0 or T2, N0, M0 * Stage IIIA - T2a/b, N2, M0 or T3, N1, M0 or T4, N0, M0 * Stage IIIB - T3, N2, M0 * Stage IV - T1-3, N3, M0 or T4, N1-3, M0, or any T, any N, M1

* Stage 0 - Tis, N0, M0

* Stage IA - T1, N0 or N1, M0

* Stage IB - T1, N2, M0 or T2a/b, N0, M0

* Stage II - T1, N2, M0 or T2a/b, N1, M0 or T2, N0, M0

* Stage IIIA - T2a/b, N2, M0 or T3, N1, M0 or T4, N0, M0

* Stage IIIB - T3, N2, M0

* Stage IV - T1-3, N3, M0 or T4, N1-3, M0, or any T, any N, M1

Title Stage 4

Stage 4

Title

Treatment Surgery is the only curative treatment for gastric cancer. It is the best palliation provides the most accurate staging.

Surgery is the only curative treatment for gastric cancer.

It is the best palliation

provides the most accurate staging.

Exceptions patients who cannot tolerate an abdominal operation, and patients with overwhelming metastatic disease.

patients who cannot tolerate an abdominal operation, and

patients with overwhelming metastatic disease.

Goal of Treatment resection of all tumor all margins (proximal, distal, and radial) should be negative and an adequate lymphadenectomy performed negative margin of at least 5 cm

resection of all tumor

all margins (proximal, distal, and radial) should be negative and an adequate lymphadenectomy performed

negative margin of at least 5 cm

Subtotal gastrectomy standard operation for gastric cancer is radical subtotal gastrectomy

standard operation for gastric cancer is radical subtotal gastrectomy

Lower radical partial gastrectomy carcinoma of the lower third of the stomach. ligation of the left and right gastric and gastroepiploic arteries at the origin en bloc removal of the distal 75% of the stomach, including the pylorus and 2 cm of duodenum the greater and lesser omentum, and all associated lymphatic tissue

carcinoma of the lower third of the stomach.

ligation of the left and right gastric and gastroepiploic arteries at the origin

en bloc removal of the distal 75% of the stomach, including the pylorus and 2 cm of duodenum

the greater and lesser omentum, and all associated lymphatic tissue

Reconstruction Reconstruction is usually by Billroth II gastrojejunostomy, if a small gastric remnant is left (<20%), a Roux-en-Y reconstruction is considered.

Reconstruction is usually by Billroth II gastrojejunostomy,

if a small gastric remnant is left (<20%), a Roux-en-Y reconstruction is considered.

Esophagogasrectomy growth involving the cardia and gastroesophageal junction

growth involving the cardia and gastroesophageal junction

Upper radical partial gastrectomy Growths of upper third Reconstruction esophagogastrostomy Pyloroplasty An isoperistaltic jejunal interposition (Henley loop) between the esophagus and antrum could be considered.

Growths of upper third

Reconstruction

esophagogastrostomy

Pyloroplasty

An isoperistaltic jejunal interposition (Henley loop) between the esophagus and antrum could be considered.

Total Gastrectomy Survival similar compared with subtotal gastrectomy Complications higher Total gastrectomy with jejunal pouch/ esophageal anastomosis may be the best operation for patients with proximal gastric adenocarcinoma ,linitis plastica

Survival similar compared with subtotal gastrectomy

Complications higher

Total gastrectomy with jejunal pouch/ esophageal anastomosis may be the best operation for patients with proximal gastric adenocarcinoma ,linitis plastica

Reconstruction

Lymphadenectomy The extent of resection is described as D1. Limited Lymphadenectomy. All N1 Nodes removed en bloc with the stomach D2. Systematic Lymphadenectomy. N1 & N2 nodes en bloc with stomach D3. Extended Lymphadenectomy. A more radical en bloc resection including N3 nodes

The extent of resection is described as

D1. Limited Lymphadenectomy. All N1 Nodes removed en bloc with the stomach

D2. Systematic Lymphadenectomy. N1 & N2 nodes en bloc with stomach

D3. Extended Lymphadenectomy. A more radical en bloc resection including N3 nodes

Extent of lymphadenectomy Two randomized trials compared D1 with D2 lymphadenectomy in patients who were treated for curative intent. postoperative morbidity (43% versus 25%) and mortality (10% versus 4%) were higher in the D2 group. Drawback

Two randomized trials compared D1 with D2 lymphadenectomy in patients who were treated for curative intent.

postoperative morbidity (43% versus 25%) and mortality (10% versus 4%) were higher in the D2 group.

Drawback

Recommended A pancreas and spleen-preserving D2 lymphadenectomy

A pancreas and spleen-preserving D2 lymphadenectomy

Carcinoma upper third

Carcinoma middle third

Carcinoma lower third

Post op complications Early complications Paralytic ileus. Leakage from suture line. Leakage from duodenal stump. Acute Cholycystitis, Pancreatitis Stomal obstruction.

Early complications

Paralytic ileus.

Leakage from suture line.

Leakage from duodenal stump.

Acute Cholycystitis, Pancreatitis

Stomal obstruction.

Title Late complications Early Dumping syndrome Late dumping syndrome. Bilious vomiting. Gastric stump cancer Vit B12 deficiency Osteoporosis

Late complications

Early Dumping syndrome

Late dumping syndrome.

Bilious vomiting.

Gastric stump cancer

Vit B12 deficiency

Osteoporosis

Adjuvant Therapy Rationale behind radiotherapy is to provide additional local-regional tumor control. Adjuvant chemotherapy is used either as a radiosensitizer or as definitive treatment for presumed systemic metastases.

Rationale behind radiotherapy is to provide additional local-regional tumor control.

Adjuvant chemotherapy is used either as a radiosensitizer or as definitive treatment for presumed systemic metastases.

Adjuvant Radiotherapy lower rates of local recurrence in patients who received postoperative radiotherapy than in those who underwent surgery alone (British stomach cancer study group) Improved survival (mayo clinic randomized patients)

lower rates of local recurrence in patients who received postoperative radiotherapy than in those who underwent surgery alone

(British stomach cancer study group)

Improved survival

(mayo clinic randomized patients)

Intra operative radiotherapy 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. Stage 3 and 4 Median survival (21 months vs 10 months ) with IORT

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.

Stage 3 and 4

Median survival (21 months vs 10 months ) with IORT

Adjuvant Chemotherapy No consistent survival benefit. Epirubicin . 5 florouracil ,cis platinium (ECF) Combination of chemoradio therapy has better outcome

No consistent survival benefit.

Epirubicin . 5 florouracil ,cis platinium (ECF)

Combination of chemoradio therapy has better outcome

Neo adjuvant chemotherapy downstaging of disease to increase resectability, decrease micrometastatic disease burden prior to surgery allow patient tolerability prior to surgery determine chemotherapy sensitivity reduce the rate of local and distant recurrences, and ultimately improve survival.

downstaging of disease to increase resectability,

decrease micrometastatic disease burden prior to surgery

allow patient tolerability prior to surgery

determine chemotherapy sensitivity

reduce the rate of local and distant recurrences, and ultimately improve survival.

Palliative Care radiotherapy provides relief from bleeding, obstruction, and pain in 50-75% wide local excision, partial gastrectomy, total gastrectomy, simple laparotomy, gastrointestinal anastomosis, and bypass for food intake or pain relief

radiotherapy provides relief from bleeding, obstruction, and pain in 50-75%

wide local excision, partial gastrectomy, total gastrectomy, simple laparotomy, gastrointestinal anastomosis, and bypass for food intake or pain relief

Summary

Thankyou