Lecture notes for medical students

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2. Objectives

3. Objectives
1. Introduction & History
2. Relevant Anatomy, Physiology
3. Aetiology
4. Pathophysiology
5. Pathology
6. Classification
7. Clinical Features
8. Investigations
9. Management
10. Prevention
11. Guidelines
12. Take home messages

4. Introduction & History.

5. Introduction & History.
• Unlike other malignancies the incidence
has dropped.
• Refregeration ?
• H. Pylori

6. Aetiology
•

7. Aetiology
• Idiopathic
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative / lifestyle
• Iatrogenic
• Psychosomatic
• Poisoing/ Toxins/ Drug induced

8. Etiology:Causes
•

9. Etiology:Causes
• Smoking
• Partial gastrectomy
• Helicobacter pylori
• A family history of stomach cancer
• People with blood type A also have an increased
risk.
• Pernicious anemia
• A diet rich in pickled vegetables, salted fish, salt,
and smoked meats
• Diet deficient in fresh fruits and vegetables

10. Etiology:Causes
• Infection with the Epstein-Barr virus.
• Obesity
• Radiation exposure: Survivors of atomic bomb
blasts have had an increased rate of stomach
cancer. Other populations exposed to radiation
may also have an increased rate of stomach
cancer.
• Li-Fraumeni syndrome

11. Etiology:Premalignant leisons
Hereditary syndromes
•

12. Etiology:Premalignant leisons
Hereditary syndromes
• Hereditary diffuse gastric cancer (HDGC)
• Lynch syndrome (hereditary nonpolyposis
colorectal cancer)
• Familial adenomatous polyposis (FAP)
• Juvenile polyposis syndrome
• Peutz-Jeghers syndrome

13. Anatomy

14. Anatomy
• Which part of stomach?

15. Anatomy
• 40% of cancers develop in the lower part,
• 40% in the middle part
• 15% in the upper part
• 10% involve more than one part of the
organ.

16. Pathophysiology
•

17. Pathophysiology
• Correa’s cascade- Helicobacter pylori infection
>chronic non-atrophic gastritis > atrophic
gastritis>intestinal metaplasia>dysplasia.
• 20-year gastric cancer risk in patients with
particular gastroscopy findings
– Normal mucosa – One in 256
– Gastritis – One in 85
– Atrophic gastritis – One in 50
– Intestinal metaplasia – One in 39
– Dysplasia – One in 19

18. Pathology
•

19. Pathology
• Macroscopic appearance.-
–

20. Pathology
• Macroscopic appearance.-
– Ulcerative
– Polypoid
– Scirrhous (ie, diffuse linitis plastica)
– Superficial spreading
– Multicentric
– Barrett ectopic adenocarcinoma.

21. Pathology
• Macroscopic appearance.-

22. Pathology
• Macroscopic appearance.-

23. Pathology: Histological types
•

24. Pathology: Histological types
• Adenocarcinoma - 90-95%
• Lymphomas - 1-5%
• Gastrointestinal stromal tumors (GIST
formerly classified as either leiomyomas or
leiomyosarcomas) - 2%
• Carcinoids - 1%
• Adenoacanthomas - 1%
• Squamous cell carcinomas - 1%

25. Clinical Features
•

26. Clinical Features
• Demography
• Symptoms
• Signs
• Prognosis
• Complications

27. Demography
•

28. Demography
• Once the second most common cancer
worldwide, stomach cancer has dropped to
fourth place, after cancers of the lung,
breast, and colon and rectum.
• Highest in Asia and parts of South America
and lowest in North America.
• Japan most common cancer site in males.
• Most patients are elderly at diagnosis. The
median age for gastric cancer in the United
States is 69 years

29. Symptoms
•

30. Symptoms
Early disease has no associated symptoms; Most symptoms
of gastric cancer reflect advanced disease
•

31. Symptoms
Early disease has no associated symptoms; Most symptoms
of gastric cancer reflect advanced disease
• Indigestion
• Nausea or vomiting
• Dysphagia
• Postprandial fullness
• Loss of appetite
• Melena
• Hematemesis
• Weight loss
• Lump in abdomen

32. Late Symptoms
•

33. Late Symptoms
• Pathologic peritoneal and pleural effusions
• Obstruction of the gastric outlet
gastroesophageal junction, or small bowel
• Bleeding in the stomach from esophageal
varices or at the anastomosis after surgery
• Intrahepatic jaundice caused by
hepatomegaly
• Extrahepatic jaundice
• Weight loss resulting from starvation or
cachexia of tumor origin

34. Signs
•

35. Signs
All physical signs are late events.
•

36. Signs
All physical signs are late events.
• palpable enlarged stomach with succussion
splash;
• Hepatomegaly
• Periumbilical metastasis (Sister Mary Joseph
nodule
• Pallor from anemia
• Enlarged lymph nodes
– Virchow nodes (ie, left supraclavicular)
Troisier sign
– Irish node (anterior axillary).
– Blumer shelf (ie, shelflike tumor of the anterior

37. Signs
• Paraneoplastic syndromes such as
dermatomyositis, acanthosis nigricans, and
circinate erythemas are poor prognostic
features.
• Other associated abnormalities include
peripheral thrombophlebitis Troussaau sign
and microangiopathic hemolytic anemia.
•

38. Prognosis
•

39. Prognosis
• 5-year relative survival rate, which was
14.3% in 1975, rose to 32.0% by 2010-
2016.
• The 5-year relative survival rate by stage at
diagnosis was 69.5% for localized
disease, 32.0% for regional disease, and
5.5% for distant disease.
• Worldwide, gastric cancer is the third
leading cause of cancer death.

40. Prognosis
• Japan, Chile, and Venezuela have
developed a very rigorous early screening
program that detects patients with early-
stage disease (ie, low tumor burden).
• These patients appear to do quite well

41. Staging
TNM classification system

42. Staging
TNM classification system
• TX -
• T0 -
• Tis -
• T1 -
• T2 - .
• T3 -
• T4 -

43. Staging
TNM classification system
• TX - Primary tumor
(T) cannot be assessed
• T0 - No evidence of
primary tumor
• Tis - Carcinoma in
situ, intraepithelial
tumor
• T1 - Tumor invades
lamina propria,
muscularis mucosae,
or submucosa
• T2 - Tumor invades
muscularis .
• T3 - Tumor penetrates
subserosal connective
tissue without invasion
of visceral peritoneum
or adjacent structures
• T4 - Tumor invades
serosa (visceral
peritoneum) or
adjacent structures

44. Staging
TNM classification system
Regional lymph nodes
• NX -
• N0 -
• N1 -
• N2 -
• N3 -

45. Staging
TNM classification system
Regional lymph nodes
• NX - Regional lymph nodes (N) cannot be
assessed
• N0 - No regional lymph node metastases
• N1 - Metastases in 1-2 regional lymph nodes
• N2 - Metastases in 3-6 regional lymph nodes
• N3 - Metastases in 7 or more regional lymph
nodes

46. Staging
TNM classification system
• M0 -
• M1 -

47. Staging
TNM classification system
Distant metastasis
• M0 - No distant metastasis
• M1 - Distant metastasis

48. Staging
TNM classification system
• Stage 0 - Tis, N0, M0
• Stage IA - T1, N0, M0
• Stage IB - T2, N0, M0; or T1, N1, M0
• Stage IIA - T3, N0, M0; T2, N1, M0; or T1, N2,
M0
• Stage IIB - T4a, N0, M0; T3, N1, M0; T2, N2,
M0; or T1, N3, M0

49. Staging
TNM classification system
• Stage IIIA - T4a, N1, M0; T3, N2, M0; or T2, N3,
M0
• Stage IIIB - T4b, N0, M0; T4b, N1, M0; T4a, N2,
M0; or T3, N3, M0
• Stage IIIC - T4b, N2, M0; T4b, N3, M0; or T4a,
N3, M0
• Stage IV –M1, Any T, any N

50. Classification
•

51. Classification
• histologic description
–

52. Classification
• Adenocarcinoma of the stomach is
subclassified according to histologic
description
– Tubular
– Papillary
– Mucinous
– Signet-ring cells
– Undifferentiated lesions
•

53. Classification
• In about 5% of primary gastric cancers, a
broad region of the gastric wall or even the
entire stomach is extensively infiltrated by
malignancy, resulting in a rigid thickened
stomach, termed linitis plastica. Patients
with linitis plastica have an extremely poor
prognosis.

54. Classification
• The Lauren system classifies gastric cancer
pathology
– Type I (intestinal)
– Type II (diffuse).

55. Prognosis

56. Prognosis
• Stage 0 - Greater than 90%
• Stage Ia - 60-80%
• Stage Ib - 50-60%
• Stage II - 30-40%
• Stage IIIa - 20%
• Stage IIIb - 10%
• Stage IV - Less than 5%.

57. Prognosis
• Stage 0 - Greater than 90%
• Stage Ia - 60-80%
• Stage Ib - 50-60%
• Stage II - 30-40%
• Stage IIIa - 20%
• Stage IIIb - 10%
• Stage IV - Less than 5%.

58. Investigations
•

59. Investigations
• Laboratory Studies
– Routine
– Special
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC
– Histlogy

60. Investigations
Laboratory Studies
•

61. Investigations
Laboratory Studies
• CBC: anemia
• Electrolyte panels
• Liver function tests
• Tumor markers such as CEA and CA 19-9:
Elevated CEA in 45-50% of cases; elevated
CA 19-9 in about 20% of cases
• HER2-neu testing if metastatic
adenocarcinoma is documented or
suspected

62. Diagnostic Studies
Imaging Studies
•

63. Diagnostic Studies
Imaging Studies
• X-Ray Chest
– Double-contrast upper GI series and barium
swallows.
• USG
• CT / PET CT
• Angiography
• MRI
• Endoscopy*/ EUS
• Nuclear scan

64. Diagnostic Studies
Imaging Studies
• Finding early gastric cancer

65. Differential Diagnosis
• •

66. Differential Diagnosis
• Acute Gastritis
• Atrophic Gastritis
• Bacterial
Gastroenteritis
• Chronic Gastritis
• Esophageal Cancer
• Esophageal Stricture
•
• Esophagitis
• Malignant Neoplasms
of the Small Intestine
• Non-Hodgkin
Lymphoma
• Peptic Ulcer Disease
• Viral Gastroenteritis

67. Operative Therapy
•

68. Operative Therapy
• Tis, or T1-- Endoscopic mucosal resection
or surgery are the standard treatment
options
• Stage IB to IIIC(resectable tumors)
preoperative chemotherapy or
chemoradiotherapy followed by surgery.
• Postoperative chemoradiation or
chemotherapy is indicated for patients who
have undergone primary D2 lymph node
dissection

69. Minimally invasive Therapy
• Endoscopic resection for early-stage
cancers

70. Operative Therapy
•

71. Operative Therapy
• Total gastrectomy
• Esophagogastrectomy
• Subtotal gastrectomy
• Lymph node dissection: Controversy exists
regarding extent of dissection; the National
Comprehensive Cancer Network (NCCN)
recommends D2 dissections over D1
dissections.

72. Palliative Chemotherapy

73. Palliative Chemotherapy
• For patients with unresectable tumors,
palliative fluoropyrimidine- or taxane-based
chemoradiotherapy or chemotherapy

74. Chemotherapy, Targeted therapy

75. Chemotherapy, Targeted therapy
• Platinum-based combination chemotherapy:
– epirubicin/cisplatin/5-FU
– docetaxel/cisplatin/5-FU
– rinotecan and cisplatin
– oxaliplatin and irinotecan
• Trastuzumab(Herceptin)with cisplatin and
capecitabine or 5-FU in HER-2neu +
• Ramucirumab

76. Neoadjuvant, adjuvant, and palliative
therapies
• Neoadjuvant chemotherapy
• Intraoperative radiotherapy (IORT)
• Adjuvant chemotherapy (eg, 5-FU)
• Adjuvant radiotherapy
• Adjuvant chemoradiotherapy
• Palliative radiotherapy
• Palliative-intent procedures (eg, wide local
excision, partial gastrectomy, total
gastrectomy, simple laparotomy,
gastrointestinal anastomosis, bypass)

77. Prevention
•

78. Prevention
• Screening
• Control environmental factors
• Management of precancerous conditions

79. Screening

80. Screening
• Photofluorography
• Endoscopy
• Serum pepsinogen testing
• Helicobacter pylori antibody testing.

81. Control environmental factors
•

82. Control environmental factors
• Smoking
• Diets high in salt, smoked foods, salted fish
and meat, and pickled vegetables
• Eradicate Helicobacter pylori infection
• Previous gastric surgery
• Pernicious anemia
• Adenomatous polyps
• Chronic atrophic gastritis
• Radiation exposure

83. Management of precancerous
conditions
• .

84. Management of precancerous
conditions
• Magnification chromoendoscopy or narrow-
band imaging (NBI) endoscopy
• Biopsies
• Endoscopic surveillance every 3 years
• H pylori infection is present>eradication
• Polyps with high-grade dysplasia that
cannot be removed, or invasive cancer
detected on biopsy should be referred for
gastrectomy.

85. Management of precancerous
conditions: HDGC
•

86. Management of precancerous
conditions: HDGC
• Mutations of the E-cadherin gene (CDH1)
• Prophylactic gastrectomy (without a D2
lymph node dissection) between the ages of
18 and 40 for asymptomatic carriers with a
family history of HDGC
• Women with CDH1 mutations are at
increased risk for breast cancer and should
be followed similar
to BRCA1/ BRCA2 mutation carriers

87. Breast Cancer Prevention
for BRCA1and BRCA2 Mutation
Carriers
• For women who carry a mutation in
the BRCA1 or BRCA2 genes, the risk of
breast cancer by age 70 years is
approximately 65% and 45%,
respectively. Breast cancer prevention for
these women has predominantly focused on
surgical strategies, such as bilateral
mastectomy and endocrine ablation by
premenopausal bilateral salpingo-
oophorectomy (BSO).

88. Breast Cancer Prevention
for BRCA1and BRCA2 Mutation Carriers
• Who decline bilateral mastectomy, or
choose to delay it until they are older,
tamoxifen should be considered,

89. Take home messages
• Ca.Stomach when detected is incurable.
• Several silver linings
– Falling incidence
– Early detection
– H. Pylori eradication.
• Our role
– Order endoscopy and H.pylori testing instead of
just prescribing PPIs.

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