A short overview of the anatomy, clinical features, and management of carcinoma of stomach

1. GASTRIC CANCER

2. ANATOMY OF STOMACH
• CARDIA – most proximal
part of stomach
• FUNDUS – superior most
part of stomach
• BODY (CORPUS) – largest
portion
• ANTRUM
• PYLORUS – connects distal
stomach(antrum)
to proximal duodenum

3. BLOOD SUPPLY OF STOMACH
• via COELIAC ARTERY
• Four main arteries
Left Gastric
Right Gastric
Left Gastroepiploic
Right Gastroepiploic
• Also
Inferior Phrenic arteries
Short Gastric arteries

4. LYMPHATIC DRAINAGE
• Lymphatic drainage parallels the vasculature
• Drains to four zones of lymph nodes
• All four zones drain into coeliac group and
subsequently to thoracic duct

5. D1 and D2 lymph nodes
D1 D2
D3 – para-aortic and interaorto caval nodes

6. GASTRIC CANCER
• Malignant neoplasms derived from any of the
histologic components that make up the stomach
Adenocarcinoma (90%) – derived from epithelium
Lymphoma
Carcinoid
GIST
• Prognosis tends to be poor
• Early diagnosis is the key

7. RISK FACTORS
NUTRITIONAL
Low fat or protein consumption
Salted meat or fish
High nitrate and complex carbohydrate consumption
ENVIRONMENTAL
Smoking
Lack of refrigeration
Poor food preparation and drinking water
MEDICAL
H pylori infection
Prior gastric surgery, gastric atrophy, adenomatous
polyp

9. Morphological classification

10. • LAUREN Classification
for adenocarcinoma
Based on histology
INTESTINAL TYPE
• More well differentiated
• Arises in a precancerous
condition (gastric atrophy,
intestinal metaplasia)
• M>F, increases with age
• Hematogenous spread
• Gland formation(+)
DIFFUSE TYPE
• Poorly differentiated
• Clusters of signet ring cells
• Tends to spread
submucosally
• Early metastasis via
transmural extension and
lymphatics
• F>M, in slightly younger
individuals
• Poorer prognosis

11. WHO System of classification of GASTRIC CARCINOMA
• Adenocarcinoma
• Adenosquamous cell carcinoma
• Squamous cell carcinoma
• Undifferentiated carcinoma
• Unclassified carcinoma

12. CLINICAL FEATURES – SYMPTOMS
• Generally non specific
• Advanced tumor
Asymptmatic
Epigastric pain
Early satiety
Fatigue
Weight loss
Obstruction
Dysphagia
Persistent
vomiting
GI bleed

14. CLINICAL FEATURES
• Anemia
• Palpable abdominal mass
• Lymphadenopathy
Left Supraclavicular (Virchow’s) node
Irish nodule : Left axillary lymphadenopathy
• Periumbilical (Sr Mary Joseph) nodule- peritoneal
mets via ?ligament
• Intraabdominal metastasis
– Hepatomegaly, Jaundice, Ascites
– Krukenberg tumor
– Blumer shelf (peritoneal mets)

16. Emergency presentation
• Gastric outlet obstruction
– projectile vomiting (of
undigested food, devoid of any
bile); Visible Peristalsis from
left to right; Succussion splash;
positive ausculto-percussion
test etc.
• Gastric Perforation
– Abdominal pain, tenderness,
rebound tenderness, guarding,
rigidity

17. INVESTIGATIONS
• Routine blood investigations, X rays
• Upper GI endoscopy
• Contrast enhanced CT scan
• Endoscopic ultrasonogram
• PET

18. TNM staging

19. TNM staging

20. • EARLY GASTRIC CANCER : cancer limited to
the mucosa and submucosa with or without
lymph node involvement (T1, any N)
• ADVANCED GASTRIC CANCER
• METASTATIC CANCER

21. ENDOSCOPY
• Visualisation of
tumor
• Biopsy – multiple
specimen
• (6-8 from different
sites
• If < 2cm
Endoscopic Mucosal
Resection (EMR)

22. ENDOSCOPIC ULTRASOUND
• Endoscopy combined with ultrasound
• Most accurate evaluation of DEPTH of
tumor invasion (T)
• Possible NODAL involvement
• Helps in differentiating between high risk
and low risk patients

23. CROSS SECTIONAL IMAGING
• CECT scan
– Chest, abdomen and pelvis with oral and IV
– Extend of the disease
–Involvement of adjacent organs
– For detecting metastatic disease
• PET/CT scan
– Effective for monitoring response to
therapy
-- To look for metastasis

24. DIAGNOSTIC LAPAROSCOPY
• Can detect occult peritoneal metastatic
disease even when CT is negative

25. TREATMENT
• Three main treatment plans
• RESECTION with or without ADJUVANT
therapy
• NEOADJUVANT therapy followed by
RESECTION
• Treatment of systemic disease WITHOUT
resection

26. SURGICAL THERAPY
• AIM : Complete resection with a wide margin of normal
stomach
Proximal 5 cms margin and distal 1 cm margin
• CANDIDATES : No metastatic disease
No invasion of unresectable vascular structure
(aorta, celiac trunk, proximal common hepatic, Proximal splenic
arteries)
• For T4 tumours : Organ with invasion is removed enbloc with
gastrectomy specimen

27. Extent of resection
Distal / subtotal
gastrectomy
Total gastrectomy

28. Roux – en – Y
esophago-
jejenostomy
Subto
tal
Total
gastrectomy
Billroth I Billroth II

29. LYMPHADENECTOMY
• D1 lymphadenectomy : only perigastric nodes are
removed
• D2 lymphadenectomy : LNs along the named vassels with
or without splenectomy
• D3 lymphadenectomy : complete clearance of celiac axis
and peri-aortic nodes – Not usually done
• Clearance of more number of lymph nodes is associated
with higher levels of morbidity and mortality

30. • For gastric ca without LN mets
– Total/ subtotal gastrectomy + D1
lymphadenectomy
• with CT evidence of LN mets
– Total/ subtotal gastrectomy + D2
lymphadenectomy

31. POSTOPERATIVE COMPLICATIONS
, Duodenal stump
leak

32. Dumping Syndrome
• It is a group of symptoms that may result from
having part of the stomach removed or from
other surgery involving the stomach.
• symptoms range from mild to severe
• often subside with time

33. Early : 30 to 60 minutes after meals
• A feeling of fullness, even after eating just a small amount
• Abdominal cramping or pain
• Nausea or vomiting
• Severe diarrhea
• Sweating, flushing, or light-headedness
• Rapid heartbeat
Causes:
•The small intestine stretches
•High concerntration
•Water pulled out of the bloodstream moves into the small
intestine.
•Hypovolumia , Hypotension

34. Late : 2 to 3 hours after eating
• Fatigue or weakness
• Flushing or sweating
• Shakiness, dizziness, fainting, or passing out
• Loss of concentration or mental confusion
• Feelings of hunger
• Rapid heartbeat
•Sugar rich food reaching the duodenum
•Causing the blood glucose to spike up
•Excessive insulin secretion
•Hypoglycaemia

35. Treatment
• Dietary modification
• likely to resolve on its own within three
months
• Octreotide – for severe cases

36. CHEMOTHERAPY
Neo adjuvant chemo
For locally advanced tumor (T3/T4/N+)
• ECF regime - Combination of Epirubicin, Cisplatin, and 5-FU
• FLOT regime – 5FU , Leucoverin, Oxaliplatin, Taxane
Adjuvant Chemo
After surgery – 6 cycles

37. RADIOTHERAPY
• For positive margins and residual disease
• Palliative purposes

38. PALLIATIVE SURGERY
• Obstruction or bleeding
• Gastric Exclusion procedure and
esophagojejunostomy
• Palliative stenting

39. THANK YOU