Metastatic carcinoma of stoamch


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  • This regional difference has been attributed to environmental factors. There is a continuing worldwide decline in prevalence and death rate. The reduction in the incidence of gastric carcinoma may reflect primarily a decline in carcinomas of the distal stomach.
  • For example, the age-adjusted death rate per 100,000 population for gastric cancer varies dramaticly in the world. The black area is the area with more than 30/100,000 population of GC, including Russia, east Asia, Chile and Costa Rica. Gray area was the country with moderate GC death rate, including India, Parkinstain; while area was the area with lowest GC death rate including North America, Western European.
  • The development of gastric cancer is a multi-factor process. A large number of risk factors have been associated with gastric cancer. These include dietary factor, smoking, H. pylori infection, low gastric acidity, genetic factors. Excessive intake of salt or salty food, low consumption of fresh fruits and vegetables are likely contribute to the development of gastric cancer. Studies had indicated there was a significant association between cigarette smoking and gastric cancer risk, particularly in male smokers. H. pylori is a definite carcinogen accounting for at least 300 000 new cases of gastric cancer each year worldwide. Familiar studies have found that the risk of developing gastric cancer for relatives of cases is increased two- to three-fold suggesting a role of genetic factors. Low gastric acidity may increase intraluminal formation of N-nitroso compounds which are carcinogens.
  • The association between chronic Helicobacter pylori infection and development of gastric cancer is well established. The international Agency for Research on Cancer has categorized H. pylori as a group I carcinogen at year of 1994. Experimental evidence lacking at that and been provided by using Mongolian gerbil model after long term infection and with or without treatment using low dose chemical carcinogens. during the later 1990s. It means H. pylori infection is a cause of gastric cancer with estimates of attributable risk ranging from 50%~73%.
  • Metastatic carcinoma of stoamch

    1. 1. Metastatic Adenocarcinoma of Stomach
    2. 2. • Adenocarcinoma of the Stomach • Definition • Malignant gland forming neoplasm of the stomach, exclusive of the EGJ and gastric cardia
    3. 3. Gastric Cancer Epidemiology Forth common types of cancer Second most common cancer related death Geographic variations (ten times) Continuing decline Primarily a decline of distal GC (2000) (2000)
    4. 4. Geographic variations
    5. 5. Gastric Cancer Environmental factors H. pylori Genetic factors Etiological Factors of Gastric Cancer Precancerous changes
    6. 6. The role of H. Pylori infection in gastric carcinogensis Type I carcinogen 1994 by IARC Gastric Cancer Attributable risk 50%~73% Epidemiological studie
    7. 7. Environmental factors Environmental factors are involved Japanese immigrants in US: 25% Second generation: >50% Subsequent generations: comparable to General US population
    8. 8. Environmental factors Lower socioeconomic status Tobacco/alcohol Fresh vegetable/fruits /Micronutrition Poor food storage Eating salted/ Smoked food Mucosal damage Pro-carcinogen/ Carcinogen Lack of antioxidant G A S T R I C C A N C E R C
    9. 9. Genetic factors • The majority of gastric tumor are sporadic in nature • There are rare inherited gastric cancer predisposition.
    10. 10. Precancerous changes Precancerous lesions Precancerous conditions
    11. 11. Precancerous lesions • Defined as those pathological changes predisposed to gastric cancer dysplasia • 10% of patients may progress in severity • majority of patients either regress or remain stable • High-grade dysplasia may be only a transient phase in the progression to gastric cancer • occurs in atrophic gastritis or intestinal metaplasia
    12. 12. Nature history of gastric dysplasia No Dysplasia No Dysplasia Mild Dysplasia Mild Dysplasia Moderate Dysplasia Moderate Dysplasia High-grade Dysplasia High-grade Dysplasia Gastric adenocarcinoma Gastric adenocarcinoma 5 years5 years 5 years5 years 5 years5 years 3 months-2 years3 months-2 years 10%10% 10%10% 50%-90%50%-90% 60%60% 60%60% 10%10%
    13. 13. Precancerous condition • Defined as those clinical setting with higher risk of developing gastric cancer Chronic atrophic gastritis Gastrectomy Pernicious anemia Menetrier’s disease Chronic gastric ulcer Gastric polyps
    14. 14. Postulated sequence of histologic events in the progression to gastric adenocarcinoma and potential contributory factors H. Pylori H. Pylori Other factors Other factors Chronic Superficial Gastritis Chronic Superficial Gastritis Intestinal Metaplasia Intestinal Metaplasia Atrophic Gastritis Atrophic Gastritis DysplasiaDysplasia FAP or Adenomas FAP or Adenomas Gastric Adenocarcinoma Gastric Adenocarcinoma Other factors Other factors Association Association Strong Association Strong Association
    15. 15. Pathology Stages Morphology Pathohistologic classification Metastasis
    16. 16. Stages • Early stage limited in the mucosa and sub mucosa layers, no matter with or without lymph node metastasis Classified by the Japanese Society for Gastric Cancer <1cm <0.5cm • Advanced stage invaded over sub mucosa According to Bormann’ classification
    17. 17. TNM classification (UICC) 0 Tis N0 M0 III A T2 N2 M0 I A T1 N0 M0 T3 N1 M0 I B T1 N1 M0 T4 N0 M0 T2 N0 M0 III B T3 N2 M0 II T1 N2 M0 IV T4 N2 M0 T2 N1 M0 T1~3 N3 M0 T3 N0 M0 any T any N M1
    18. 18. Morphology---Early stage
    19. 19. Morphology---Early stage
    20. 20. Morphology---Early stage
    21. 21. Morphology ---Advanced stage
    22. 22. Histopathological classification Histology Adenocarcinoma 90% Lymphoma 5% Stromal 2% Carcinoid <1% Metastasis <1% Adenosquamous/squamous <1% Miscellaneous <1%
    23. 23. Origin (Lauren) • Intestinal type associated with most environmental risk factors carries a better prognosis shows no familial history • Diffuse type consists of scattered cell clusters with poor prognosis
    24. 24. Growth pattern (Ming) • Expanding type grew en mass and by expansion resulting in the formation of discrete tumor nodules with relatively good prognosis • Infiltrative type invaded individually with poor prognosis
    25. 25. Metastasis Direct invasion Lymph node dissemination Blood spread Intraperitoneal colonization
    26. 26. Special term • Blumer shelf A shelf palpable by rectal examination, due to metastatic tumor cells gravitating from an abdominal cancer and growing in the rectovesical or rectouterine pouch • Krukenberg tumor A tumor in the ovary by the spread of stomach cancer
    27. 27. Clinical manifestation Signs and Symptoms Early Gastric Cancer Asymptomatic or silent 80% Peptic ulcer symptoms 10% Nausea or vomiting 8% Anorexia 8% Early satiety 5% Abdominal pain 2% Gastrointestinal blood loss <2% Weight loss <2% Dysphagia <1%
    28. 28. Signs and Symptoms Advanced Gastric Cancer Weight loss 60% Abdominal pain 50% Nausea or vomiting 30% Anorexia 30% Dysphagia 25% Gastrointestinal blood loss 20% Early satiety 20% Peptic ulcer symptoms 20% Abdominal mass or fullness 5% Asymptomatic or silent <5% Duration of symptoms Less than 3 month 40% 3-12 months 40% Longer than 12 month 20%
    29. 29. Special signs & terms • Linitis plastica: diffusely infiltrating with a rigid stomach • Virchow’s node: supraclavicular lymphadenopathy (left) • Irish’s node: axillary lymphadenopathy • Sister Mary Joseph’s node: umbilical lymphadenopathy
    30. 30. Sister Mary Joseph’s node
    31. 31. Laboratory tests Iron deficiency anemia Fecal occult blood test (FOBT) Tumor markers (CEA, Ca19-9)
    32. 32. Diagnosis Endoscopic diagnosis --- biopsy needed for definitive diagnosis Radiologic diagnosis Detection of early gastric cancer
    33. 33. Endoscopic diagnosis • In patients with signs and symptoms suggestive of GC, and/or with compatible risk factors or paraneoplastic conditions, the diagnostic procedure of choice could be an endoscopic examination • The diagnostic criteria for early or advanced gastric cancer under endoscopy are based on the JRSGC and Bormann’s classification
    34. 34. Endoscopic features of gastric cancer
    35. 35. Radiologic diagnosis • For reasons of cost and availability, radiography may sometimes be the first diagnostic procedure performed • Classic radiography signs of malignant gastric ulcer asymmetric/distorted ulcer crater ulcer on the irregular mass irregular/distorted mucosal folds adjacent mucosa with obliterated /distorted area gastric nodularity, mass effect, or loss of dispensability
    36. 36. Radiologic diagnosis Distal GC Proximal GC Linitis plastica
    37. 37. Detection of early gastric cancer • Endoscopic screening general population or high risk persons • Careful observation
    38. 38. Differential diagnosis Gastric Cancer Gastric Ulcer
    39. 39. Complications • GI bleeding 5% • Pylorus/cardia obstruction • Perforation ulcer type
    40. 40. Treatment Surgical resection EMR Adjuvant therapy Palliative therapy
    41. 41. Endoscopic mucosal resection Gastric cancer lesion confined to mucosa layer Endoscopic ultrasound (EUS) is helpful in stageing GC
    42. 42. Endoscopic mucosal resection
    43. 43. Endoscopic mucosal resection
    44. 44. Chemotherapy Regimen Approximate Survival Response rate Benefit Fluorouracil +doxorubicin 30% No + mitomycin (FAM) Fluorouracil + doxorubicin 30% No Semustine (FAMe) Fluorouracil + doxorubicin 30% No + cisplatin (FAP) Etoposide + doxorubicin 40% No + cisplatin (EAP) Etoposide + leucovorin 30% No + fluorouracil (ELF) Fluorouracil +doxorubicin 40% Unconfirmed
    45. 45. AIM OF COMBINATION THERAPY INCREASED EFFICACYINCREASED EFFICACY Different mechanisms of action Compatible side effects Different mechanisms of resistance ACTIVITYACTIVITY SAFETYSAFETY
    46. 46. Side effects of chemotherapy Mucositis Nausea/vomiting Diarrhea Cystitis Sterility Myalgia Neuropathy Alopecia Pulmonary fibrosis Cardiotoxicity Local reaction Renal failure Myelosuppression Phlebitis
    47. 47. Metal stent
    48. 48. Prognosis • The TNM classification/staging of gastric cancer is the best prognostic indicator • The 5 years survival rate depends on the depth of gastric cancer invasion • Patients in whom tumors are resectable for cure also have good prognosis
    49. 49. Prevention • Eradication of H. Pylori infection in those high risk population family history of gastric cancer chronic gastritis with apparent abnormality (atrophy, IM) post early gastric cancer resection gastric ulcer • Management of dietary risk factor intake adequate amount of fruits, vegetables minimize their intake of salty/smoked foods
    50. 50. Prevention • Tightly follow up those with precancerous condition • Endoscopic or radiologic screening