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1. Gastric Cancer
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2. • Diagnosis of Gastric Disease
– Signs and symptoms
– Diagnostic tests
• Adenocarcinoma of stomach
• Gastric cancer surveillance
• Gastric resection and reconstruction

3. DIAGNOSIS OF GASTRIC DISEASE

4. Signs and Symptoms
• None is specific but history and physical
examination would help
• Pain
• Weight loss
• Early satiety and anorexia
• Nausea and vomiting
• Bloating
• = dyspepsia or indigestion

5. Diagnostic Tests
• Esophagogastroduodenoscopy (EGD)
– Alarm symptoms indicated the need for EGD
• Weight loss
• Recurrent vomiting
• Dysphagia
• Anemia
• bleeding
– All patients with gastric cancer should have multiple
biopsy specimen both for ruling out gastric cancer and
urease test
– Complications: perforation, aspiration, and respiratory
depression

6. Diagnostic Tests
• Radiologic tests
– Plain abdominal X-rays: helpful in:
• Gastric perforation (pneumoperitoneum)
• Delayed gastric emptying (large air-fluid level)
– Double-contrast upper GI series: better than EGD
when:
• Gastric diverticula
• Fistula
• Tortuosity
• Stricture location
• Size of hiatal hernia

7. https://radiopaedia.org/cases/bowel-perforation-pneumoperitoneum

8. https://ispub.com/IJGE/8/2/6679#

9. Diagnostic Tests
• CT and MRI
– For staging work up in patients with malignant
gastric tumor (M)
• EUS
– Local staging (T, N)
– Consider neoadjuvant chemoradiation in patients
with transmural/node positive
– Tumor confined to mucosa may be considered
EMR

10. https://www.slideshare.net/aminamedonco/gastric-cancer-investigations-and-management

11. Diagnostic Tests
• Gastric secretory analysis
– Intubation stomach and monitoring gastric acid
output
• Scintigraphy
– Evaluation of gastric emptying  ingestion of a
test meal with isotopes and scanning patient
under a gamma camera

12. Diagnostic Tests
• Tests for Helicobacter pylori:
– H.pylori
• Etiologic association with PU, MALT, gastric cancer
– Urease test
– CLO test

13. ADENOCARCINOMA OF STOMACH

14. Epidemiology
• Globally:
– 4th most common cancer type
– 2nd leading cause of cancer death
• 5-year survival rate is 27%
• 85% of gastric neoplasm (4% from lymphoma,
1% from malignant GIST)

15. Risk Factors
• Family history of gastric cancer
• Pernicious anemia
• High nitrates, salt, fat dietary
• H.pylori
• EBV
• genetic: p53, COX-2, E-caherin, c-erb B-2, APC
• Previous gastrectomy or gastrojejunostomy > 10 years ago
• Tobacco use
• Menetrier disease (massive gastric folds, excessive mucous production
with protein loss, little acid production)
• Familial polyposis
• Gastric adenomas
• HNPCC
• Atrophic gastritis, intestinal metaplasia, dysplasia

16. https://www.studyblue.com/notes/note/n/stomach/deck/10417181

17. Factors decreasing risk of
gastric cancer
• Aspirin
• High fresh fruit and vegetable diet
• Vitamin C

18. Premalignant Conditions
• Polyps
– Benign gastric polyps: neoplastic (adenoma and
fundic gland polyp) and nonneoplastic
(hyperplastic, inflammatory, hamartomatous)
– Hyperplastic polyp >2cm: may harbor dysplasia or
CIS
– Polyp > 1 cm should be removed to confirm
diagnosis

19. • Atrophic gastritis
– Most common of precursor of gastric cancer
– Involved with H.pylori
• Intestinal metaplasia
• Gastric remnant cancer
Premalignant Conditions

20. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015.

21. Gross Morphology: Borrmann Classification
• Polypoid: intraluminal without ulcerated
• Fungating: intraluminal with ulcerated
• Ulcerative: mass in wall of stomach
– self-descriptive
• Scirrhous: mass in wall of stomach
– Linitis plastica
– Infiltrate entire thickness of stomach
– Cover a very large surface area
– Poor prognosis

22. Brunicardi FC et al. Schwartz’s Principles of
Surgery. 10th ed. McGraw-Hill Education, 2015.

23. Histology
• Lauren classification
– Intestinal type
• Less aggressive
• Well-differentiated
• More common in older patients
– Diffuse type
• Poor-differentiated
• Younger patients
• Proximal tumor

24. Histology
• WHO classification
– Adenocarcinoma
• Papillary
• Tubular
• Mucinous
• Signet-ring cell
– Adenosquamous carcinoma
– Squamous cell carcinoma
– Small cell carcinoma
– Undifferentiated carcinoma
– others

25. Histology
• Ming Classification
– Expanding: originate as an intestinal metaplasia
– Infiltrative: emerges from individual cells

26. Clinical Manifestation
• Physical examination typically is normal
• Weight loss
• Decreased food intake due to anorexia and early satiety
• Abdominal pain
• Nausea, vomiting, bloating
• Acute GI bleeding
• Chronic occult blood loss
• Dysphagia
• Aspiration pneumonia in a patient with vomiting and
obstruction
• Signs of metastases: Virchow’s node, Sister May-Joseph
nodule, Blumer’s shelf

27. ESMO guidelines committee. Gastric cancer: ESMO clinical practice guidelines for diagnosis, treatment, and follow-
up. Ann Oncol. Downloaded from http://annonc.oxfordjournal.org/ by guest on January 7, 2017.

28. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015.

29. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015.

30. Brunicardi FC et al. Schwartz’s Principles of Surgery.
10th ed. McGraw-Hill Education, 2015.

31. • Early gastric cancer = cancer confined to
mucosa or submucosa = T1a

32. Screening
• Is effective in high-risk population
– FAP
– HNPCC
– Gastric adenoma
– Menetrier disease
– Intestinal metaplasia or dysplasia
– Remote gastrectomy or gastrojejunostomy

33. Treatment Principles
• Surgical resection is the only curative treatment
• Gross margin:
– 5 cm between tumor and gastroesophageal junction
(ESMO)
– 8 cm in diffuse cancer (ESMO)
– Proximal margin of at least 3 cm is
recommended for T2 or deeper tumors with an expansive
growth pattern (types 1 and 2) and 5 cm for those with an
infiltrative growth pattern (types 3 and 4) (Japanese 2014)
• At least 15 lymph nodes
• Multidisciplinary is mandatory

34. Consider…
• Locoregional
– Stomach
– LN
– radiation
• Systemic
– Chemotherapy
– Targeted therapy

35. Japanese gastric cancer association. Japanese gastric cancer treatment guidelines 2014 (ver.4). Gastric
Cancer (2017) 20:1-19.

36. Definitions of Gastric Surgery
• Standard gastrectomy: at least 2/3 of stomach
+ D2 LN dissection
• Non-standard gastrectomy: altered according
to tumor stage
• Modified surgery: the extent of gastric/LN
resection is reduced from standard
• Extended surgery: gastrectomy combined with
– Adjacent involved tissue
– Extended lymphadenectomy

37. • Palliative surgery:
– Relieve symptoms: bleeding, obstruction in
advanced/metastatic disease
– Gastrectomy or gastrojejunostomy
– Stomach-partitioning gastrojejunostomy: superior
to simple gastrojejunostomy
• Reduction surgery: no evidence support
(REGATTA, JCOG705/KGCA01)
Definitions of Gastric Surgery

38. stomach-partitioning gastrojejunostomy
http://jamanetwork.com/journals/jamasurgery/fullarticle/487573

39. Extent of Gastric Resection
• Total gastrectomy: total resection including cardia and
pylorus
• Distal gastrectomy:
– remove pylorus
– cardia is preserved
– Standard gastrectomy = 2/3
• Pylorus-preserving
• Proximal gastrectomy: resect cardia
• Segmental gastrectomy: preserve cardia and pylorus
• Local resection
• Non-resectional: bypass, gastrostomy, jejunostomy

40. Resection Margin
• T2 and deeper tumor:
– Expansive growth pattern: 3 cm
– Infiltrative growth pattern: 5 cm
• Examine proximal margin by frozen section when
the rules cannot be observed
• Tumor invading esophagus, 5-cm margin not
required but frozen section to ensure R0
resection
• T1: gross margin 2 cm
– Clip marking for unclear margin

41. Selection of Gastrectomy
• Standard gastrectomy for clinically node-positive
or T2 – T4a  distal or total gastrectomy
– If R0: total gastrectomy does not provide additional
benefit
• Pancreatic invasion requiring
pancreaticosplenectomy necessitates total
gastrectomy
• Total gastrectomy with splenectomy: tumor along
greater curvature and harbor metastasis to no.
4sb LN

42. Lymph Node Dissection
• Extent
– Follow according to the type of gastrectomy
conducted

43. https://www.slideshare.net/rushabhshah9231/carcinoma-stomach-seminar

44. Cameron JL, Cameron AM. Current Surgical Therapy. 11th ed. Philadelphia: Elsevier, 2014.

45. Japanese gastric cancer association. Japanese gastric cancer treatment guidelines 2014 (ver.4). Gastric
Cancer (2017) 20:1-19

46. Japanese gastric cancer association. Japanese gastric cancer treatment guidelines 2014 (ver.4). Gastric
Cancer (2017) 20:1-19

47. D2+ Lymphadenectomy
• The benefit of prophylactic para-aortic
lymphadenectomy is denied by JCOG9501
– Prognosis is poor
– Neoadjuvant chemotherapy followed by D2+ is
option
• Station 13 = M1
– But may be option for tumors invading duodenum

48. Japanese gastric cancer association. Japanese gastric cancer treatment guidelines 2014 (ver.4). Gastric
Cancer (2017) 20:1-19

49. • Differentiated type = papillary, tubular
adenocarcinoma
• Undifferentiated type = poorly differentiated
and signet-ring cell adenocarcinoma

50. Principles of Endoscopic Resection
• Considered in tumor with very low probability
of lymph node metastasis and are suitable for
en-bloc resection
• EMR = endoscopic mucosal resection
• ESD = endoscopic submucosal dissection

51. Indication for Endoscopic Resection
• Indication as a standard treatment
– Differentiated type
– UL –
– T1a
– Diameter ≤ 2 cm

52. Curative Resection
• All are fulfilled:
– En bloc resection
– Tumor size ≤ 2 cm
– Differentiated type
– pT1a
– Negative horizontal margin (HM0)
– Negative vertical margin (VM0)
– No lymphovascular invasion (ly(-), v(-))

53. After Endoscopic Resection…
• After curative
– Follow-up EGD q6-12months
• After non-curative
– Surgical treatment should be performed
– En bloc resection of a differentiated type with
HM1 as the only non-curative factor
– Piecemeal resection of differentiated type
satisfying all other criteria

54. Chemotherapy
• Indication from Japanese guidelines 2014
– Unresectable
– Recurrent
– Non-curative R2 resection
– PS 0-2
– Unresectable T4b
– Extensive nodal disease
– M1 disease: hepatic, peritoneal

55. Chemotherapy
• Indications from ACTS-GC trial as adjuvant
chemotherapy
– Pstage II, IIIA, IIIB, exclude II due to pT1/pN2-N3
– R0 gastrectomy with ≥ D2 gastrectomy
• Indications from ESMO 2016
– Stage ≥ 1B resectable

56. Chemotherapy
• First-line treatment
– If Her-2 positive  trastuzumab
– Platinum/fluoropyrimidine combination in ≥ stage
1B resectable
– S-1 (Tegafur/gimeracil/oteracil) + cisplatin
– Capecitabine + cisplatin
– For neoadjuvant: Platinum/fluoropyrimidine
combination

57. Chemotherapy
• Second-line treatment
– Monotherapy: docetaxel, irinotecan, paclitaxel

58. SUVEILLANCE

59. Japanese gastric cancer association. Japanese gastric cancer treatment guidelines 2014 (ver.4). Gastric
Cancer (2017) 20:1-19

60. Japanese gastric cancer association. Japanese gastric cancer treatment guidelines 2014 (ver.4). Gastric
Cancer (2017) 20:1-19

61. GASTRIC RESECTION

62. Distal Gastrectomy

63. Yeo CJ et al. Shackelford’s surgery of alimentary tract. 7th ed. Philadelphia: Elsevier Saunders, 2013.

64. Yeo CJ et al. Shackelford’s surgery of alimentary tract. 7th ed. Philadelphia: Elsevier Saunders, 2013.

65. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

66. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

67. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

68. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

69. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

70. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

71. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

72. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

73. Yeo CJ et al. Shackelford’s surgery of alimentary tract. 7th ed. Philadelphia: Elsevier Saunders, 2013.

74. Yeo CJ et al. Shackelford’s surgery of alimentary tract.
7th ed. Philadelphia: Elsevier Saunders, 2013.

75. Yeo CJ et al. Shackelford’s surgery of alimentary tract. 7th ed. Philadelphia: Elsevier Saunders, 2013.

76. Total Gastrectomy

77. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

78. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

79. Zinner MJ, Ashley SW. Maingot’s Abdominal
Operation. 11th ed. McGraw-Hill’s Access surgery.

80. GASTRIC RECONSTRUCTION

81. Total Gastrectomy
• Roux-en-Y esophagojejunostomy
• Jejunal interposition
• Double tract method

82. Distal Gastrectomy
• Billroth I gastroduodenostomy
• Billroth II gastrojejunostomy
• Roux-en-Y gastrojejunostomy
• Jejunal interposition

83. References
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill
Education, 2015.
Yeo CJ et al. Shackelford’s surgery of alimentary tract. 7th ed. Philadelphia: Elsevier
Saunders, 2013.
Ma J, Shen H, Kapesa L, and Zeng S. Lauren classification and individualized
chemotherapy in gastric cancer. Oncol lett. 2016 May; 11(5): 2959–2964.
ESMO guidelines committee. Gastric cancer: ESMO clinical practice guidelines for
diagnosis, treatment, and follow-up. Ann Oncol. Downloaded from
http://annonc.oxfordjournal.org/ by guest on January 7, 2017.
Japanese gastric cancer association. Japanese gastric cancer treatment guidelines
2014 (ver.4). Gastric Cancer (2017) 20:1-19.

84. References
Berlth F, Bollschweiler E, Drebber U, Hoelscher AH, Moenig S. Pathohistological
classification systems in gastric cancer: Diagnostic relevance and prognostic value.
World J Gastroenterol. 2014 May 21; 20(19): 5679–5684.
Cameron JL, Cameron AM. Current Surgical Therapy. 11th ed. Philadelphia:
Elsevier, 2014.
NCCN. Gastric cancer. Ver3. 2016.
Yeo CJ et al. Shackelford’s surgery of alimentary tract. 7th ed. Philadelphia: Elsevier
Saunders, 2013.
Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s
Access surgery.