GASTRIC CANCER

1. CASE PRESENTATION
DEPARTMENT OF GENERAL SURGERY,
Tuesday, May 23, 2023

2. Introduction
• Y.D.M
• 51 years
• male
• from Lindi
Tuesday, May 23, 2023 2

3. Chief Complaints
• Abdominal pain 3/12
• Vomiting for 3/52
Tuesday, May 23, 2023 3

4. HPI
• Patient was apparently well until 3 months ago when he started to
present with abdominal pain, at central part of upper abdomen,
• Which was gradual onset and progressively increases in severity with
time.
• Dull in nature ,non radiating pain , aggravated by taking food , no relieving
factor
Tuesday, May 23, 2023 4

5. .
• Hx of Early satiety and abdominal fullness following a meal
• 3 weeks ago patient started to present with projectile vomiting that
occurs aproximately 30 minutes after has taken meal and vomitus
contain recent eaten food and copious amount ,however the
vomitus was not stained with bood.
• Also reported history of one episode of vomiting blood ,one months
ago approximately a full cup of tea, was not accompany with
difficulty in swallowing food.
Tuesday, May 23, 2023 5

6. .
• Reported history of black tarry stool, weight loss .
• But he denied history of abdominal swelling, Change in bowel habit
blood stained in stool , swelling protruding per anus.
• In course of illness ,was not associated with gum bleeding , easily
bruises , yellowish discoloration of eyes, fever , night sweats .
Tuesday, May 23, 2023 6

7. .
He denied history of difficult in breathing , cough , chest pain
,awareness of heart beats ,easily fatigability , exertional dypnoea or
lower limb swelling .
Tuesday, May 23, 2023 7

8. • Reported hx of consuming vegatable , fruits and salted fish ,
• Denied hx of taking smoked food , cigarrete smoking , alcohol intake
, prolonged use of pain killer.
Tuesday, May 23, 2023 8

9. In The Course Of This Illness….
He attended at a peripheral health facility, where investigations were
done and patient was referred to MNH for further evaluation and
treatment.
Tuesday, May 23, 2023 9

10. • ROS
• GUS NO obstructive or irritative symptoms passing blood /tissue
shield in urine
CNS
• Loss of consciousness, intractable headache , convulsion
• MCS
• Bone pain, Joint pain
Tuesday, May 23, 2023 10

11. Past medical history
No hx of abdominal surgery,
Hx of blood transfusion
 No hx of chronic diseases DM , HTN , Asthma.
Tuesday, May 23, 2023 11

12. Family social history
• He married man lives with his wife and four children where by all
are healthy.
• work as security man and health ensured
• No history of similar presentation in family or cancer in family
Tuesday, May 23, 2023 12

13. General Examination
• Middle aged man, fully conscious,Afebrile, wasted
• Not Pale, Not jaundiced,not dypnoeic
• No vichows node , irish nodule, Iguinal lymnode enlargement
• No fine tremors, palmar erythema, leuconychia ,finger clubbing.
• No ll edema, no skin fold hypermigmentation ,
Tuesday, May 23, 2023 13

14. General Examination ct….
Vital signs
• Temp:37.0C
• PR:86 b/min
• BP:112/79mHg
• RR :16b cycle per min
• SPO2:100% on RA
Tuesday, May 23, 2023 14

15. Abdominal Examination
• Normal abdominal contour, inverted umbilicus
• Moves with respiration, no visible peristalsis.
• surgical scars/traditional mark
• No distended veins,
• epigastric mass measure 3cmby4cm upper border and lower were
not palpable ,hard rough surfaces, tender ,move with respiration,
and non pulsatile .
• no rebound tenderness ,no muscle guarding .
Tuesday, May 23, 2023 15

16. Abdominal Examination…..
• No palpable organ, no sister mery joseph nodule
• Tympanic percussion note, liver span 16cm , positive shifting dullness
• Normal bowel sounds heard, positive succussion splash test
• DRE : Normal anal verge, intact sphincter tone, smooth rectal mucosa
and palpable prostate , palpable median sulcus, go above it ,gloved
finger stained with brown feaces.
Tuesday, May 23, 2023 16

17. Respiratory System Examination
• Normal chest contour
• Symmetrical chest movement and expansion
• Trachea was centrally located
• Normal tactile vocal fremitus bilaterally
• Resonant percussion note
• vesicular breath sounds were heard
Tuesday, May 23, 2023 17

18. Cardiovascular System Exam
• Warm extremities ,capillary refill less than 2sec
• Pulse=86b/min, good volume, regular, synchronous with other
peripheral pulses
• BP=112/79mmHg
• No precordial hyperactivity, Apex beat at 5th ICS-MCL
• S1 and S2 heard, no added sounds
Tuesday, May 23, 2023 18

19. Neurological Examination
• GCS 15/15
• Intact cranial nerves
• Normal Gait, No involuntary movements, normal muscle bulkiness
• Normal tone, Power=5/5 in all groups of muscles of Upper and lower
limbs ,Normal deep tendon and superficial reflexes
• Intact sensation
Tuesday, May 23, 2023 19

20. Summary
• 51 yrs, male presenting with abdominal pain 3/12, post prandial
projectile vomiting , hematemesis , melena , weight loss , hx
consuming salted food .
• O/e wasted , epigastric mass measure 3cm by4cm hard and rough
surface,tender at epigastrium , that you can not go above or bellow
the mass, move with respiration, positive shifting dullness, positive
succussion splash test no organomegally.norml DRE findings , no
virchows node ,irish, nodule , no SMJ nodule , inguinal node.
Tuesday, May 23, 2023 20

21. Diagnosis
Pdx:
DDX:1.
2.
3.
4
Tuesday, May 23, 2023 21

22. Diagnosis
Pdx: GOO sec GASTRIC MALIGNANCY
DDX:1.MESENTERIC TUMOR
2. COLONIC TUMOR
3.PANCREATIC TUMOR
4 PYLORIC STENOSIS SEC
5.GASTRIC POLYP
Tuesday, May 23, 2023 22

23. Gastric maliginancy
• Positive finding
• Middle age ,male pt , epigastric
pain 3/12,vomiting after meal,
hx of hematemesis , melena un
intentional weight loss, salted
fish ,smoking.
• Epigastric tenderness, epigastric
mass ,ascietis,
Pancreatic tumor
• Positive
• Epigastric pain, mass at epigastrium ,
vomiting after meal,
hematemesis,melena ,hx of alcoholism ,
un intetional weight loss,malena ,
• Mass at epigastrium , ascities
• Point against ,
• No hx of recurent acute abdomen
• No features suggestive of endo or
exocrine pancreatic failure , no features
for obstructive jaundice
Tuesday, May 23, 2023 23

24. OGD
• Oesophagus with normal mucosa
• Stomach , tumor extending from body of stomach to antrum with
• Pyloric ring ,Duodenum where not able to be assessed , biopsy was
taken.
• CONCLUSION gastric tumor
Tuesday, May 23, 2023 24

25. Tissue biopsy results
• gastric carcinoma diffuse type
Tuesday, May 23, 2023 25

26. Test Value Range
CEA 172 0-5
CA19.9 109 0-37
AFP 1.9 0- 10.9
AST 22 5-34
ALT 9 0-55
BIR D 7.4 0-8.6
BIR T 3.4-20.5
Tuesday, May 23, 2023 26

27. Tuesday, May 23, 2023 27
Test Value Range
CREATENINE 46.7 4 63-- 110
UREA 1.9 3.2 - 7.4
K 3.1 3.5-5.1
NA 137 136-145
CL 105 4.98-107
MG 102 0.66-1.07

28. Tuesday, May 23, 2023 28

29. abdominal pelvic ct scan
• Findings
• Liver normal , pancreases , spleen ,kidney normal, vascular structure
appear normal.
• Para aortic region appeared normal
• Gastric
• Circumferential gastric wall thickening and enhancement , mass
extend to the duodenum associated with lumen narrowing ,
measure 7.22cm by 5.2cm .
• Free fluid in peritoneum ,
• Urinary bladder , prostate appear normal
• No bone lesion.
Tuesday, May 23, 2023 29

30. • Impression
• Enhancing mass involving gastric and duodenal with peritoneal
infiltration causing gastric and duodenal obstruction .
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31. CHEST CT scan
Tuesday, May 23, 2023 31
 Findings
 The lung fields are free of infiltrations or masses
 No bone osteoblastic /osteolytic lesion seen
 No pleural effusion seen
Impression
No lung pathology

32. Dx
• Diffuse gastric carcinoma T4aNXM1 with GOO.
Tuesday, May 23, 2023 32

33. INTRA OPERATIVE FINDINGS
• OPERATION
• Exp Laparatomy + feeding tube jejunostomy
• FINDINGS
• Gastric wall thickening and indurated (lather bottle stomach)
• Multiple peri gastric lymph node enlargement
• Multiple liver metastases found
• Ascits with peritoneal seedlings
• Transverse colon and pancreas where firmly adherent to the stomach
• Diffuse gastric cancer T4 N3 M1
Tuesday, May 23, 2023 33

34. Final dx
• DIFFUSE GASTRIC CARCINOMA T4bN3M1 with GOO
Tuesday, May 23, 2023 34

35. LITERATURE REVIEW
• MANAGEMENT OF UNRESECTABLE LOCALLY ADVANCED AND
METASTATIC DISEASE GASTRIC CANCER.
Tuesday, May 23, 2023 35

36. Management of unresectable locally
advanced and metastatic gastric cancer
• Management of unresectable or metastatic disease may include either systemic
therapy and/or chemoradiation .
• The goal is providing symptom relief and delaying progression
• Aslo the management should incorporate symptom-directed best supportive care (
Palliative/Best Supportive Care).
• For patient with metastic adenocarcinoma,HER2, PD-L1, and MSI or MMR
testing should be performed .
Tuesday, May 23, 2023 36

37. Tuesday, May 23, 2023 37
A Patient can be offered palliative/best supportive
care alone without systemic therapy ?

38. .
• The decision to offer palliative/best supportive care alone or with
systemic therapy is dependent on the patient’s performance status.
• The ECOG Performance Status (PS) Scale and the Karnofsky PS Scale
(KPS) are commonly used to assess the performance status of
patients with cancer.
• Patients with higher ECOG PS scores are considered to have worse
performance status
• However patient with lower KPS scores are associated with worse
survival for most serious illnesses.
Tuesday, May 23, 2023 38

39. Cont..
• Patients with a KPS score less 60% or an ECOG PS score >3 should be offered
palliative/best supportive care only.
• Systemic therapy or chemoradiation (only if locally unresectable and not
previously received) can be offered in addition to palliative/best supportive care
for patients with better performance status (KPS score of> 60% or ECOG PS
score less or equal 2).
Tuesday, May 23, 2023 39

40. .
• The survival benefit of systemic therapy compared with palliative/best supportive care
alone for patients with advanced gastric cancer has been shown in several randomized
trials.
• an early comparison between chemotherapy and best supportive care versus best
supportive care alone.
• overall survival (OS; 8 vs 5 months) and time to progression (5 vs 2 months) were
longer in patients receiving chemotherapy in addition to best supportive care for
advanced gastric cancer.
• (45%) had an improved or prolonged quality of life for a minimum of 4 months
compared with those who received best supportive care alone (20)
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41. PRINCIPLES OF PALLIATIVE CARE/BEST SUPPORTIVE CARE
• The goal of best supportive care is to prevent and relieve suffering and to support
the best possible quality of life for patients and their families.
• Regardless of the stage of the disease or the need for other therapies. For gastric
cancer, interventions undertaken to relieve major symptoms may result in
prolongation of life.
• Multimodality interdisciplinary approach to palliative care of the gastric cancer
patient is encouraged.
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42. MANAGEMENT OF GASTRIC OBSTRUCTION
UNRESECTABLE OR METASTATIC GASTRIC CANCER
This is aimed to reduce nausea and vomiting and when possible, allow
resumption of an oral diet.
Alleviate or bypass.
• Endoscopic Placement of enteral stent for relief of outlet obstruction,or
esophageal stent for EGJ/gastric cardia obstruction.
• Radiation therapy , EBRT,
• Surgery
• Gastrojejunostomy
• Gastrectomy in select patients
• feeding Gastrostomy (proximal tumor )
• Feeding jejunostomy (mid or distal tumor)
Tuesday, May 23, 2023 42

43. ..
• Endoscopic placement of a SEMS is a safe and effective minimally invasive
palliative treatment of patients with luminal obstruction due to advanced gastric
cancer.
• In a systematic review, patients treated with endoscopic placement of a SEMS
were more likely to tolerate oral intake and had shorter hospital stays than patients
treated with gastrojejunostomy.
• In addition , another systematic review suggest that SEMS placement may be
associated with more favorable results in patients with a relatively short life
expectancy, whereas gastrojejunostomy is preferable in patients with a more
prolonged prognosis.
Tuesday, May 23, 2023 43

44. .
• For those patient, obstruction can not be alleviated or bypassed
• F.Gastrostomy or F jejunostomy can be done .
Tuesday, May 23, 2023 44

45. PALLITIVE/SUPPORTIVE MANAGEMENT
BLEEDING GASTRIC CANCER.
• Acute bleeding is common in patients with gastric cancer and may be tumor-
related or a consequence of therapy.
• Patients with acute severe bleeding (hematemesis or melena) should undergo
prompt endoscopic assessment ,
• The efficacy of endoscopic treatment of bleeding in patients with gastric cancer is
not well-studied,
• However ,limited available data suggest that while endoscopic therapies may be
effective as initial treatment, the rate of recurrent bleeding is very high.
Tuesday, May 23, 2023 45

46. Endoscopic management of bleeding advanced
unresectable and metastatic gastric cancer .
• Widely available options for endoscopic therapies include
• injection therapy
• mechanical therapy (eg, endoscopic clip placement),
• ablative therapy (eg, argon plasma coagulation or other laser therap
• a combination of modalities
Tuesday, May 23, 2023 46

47. Role of intervention radiology and radiation
therapy.
• Interventional radiology with angiographic embolization techniques
may be useful in situations where endoscopy is not helpful.
• external beam radiation therapy (EBRT) has been shown to effectively
manage acute and chronic gastrointestinal
• surgery , palliative gastrectomy is advocated when less invasive
modalities have failed .
Tuesday, May 23, 2023 47

48. Systemic Therapy for unresectable Locally
Advanced or Metastatic Disease.
• Therapy Systemic therapy can provide palliation of symptoms, improved survival,
and enhanced quality of life in patients with locally advanced or metastatic gastric
cancer.
• First-line systemic therapy regimens with 2 cytotoxic drugs are preferred for
patients with advanced disease because of their lower toxicity.
• The use of 3 cytotoxic drugs in a regimen should be reserved for medically fit
patients with excellent PS and easy access to frequent toxicity evaluations .
• Oxaliplatin is generally preferred over cisplatin due to lower toxicity
Tuesday, May 23, 2023 48

49. Is there a Role of targeted therapy ?
• Treatment with trastuzumab is based on the presence of HER2
overexpression
• Treatment with pembrolizumab/nivolumab is based on testing for
MSI by PCR , MMR by IHC or PD-L1 expression by IHC,
• Treatment with the TRK inhibitors entrectinib and larotrectinib is
based on testing for NTRK gene fusions.
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50. Tuesday, May 23, 2023 50
THANK YOU