Carcinoma of Stomach


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Carcinoma of Stomach

  2. 2. Primary Common Primary• Adenocarcinoma (95%),• Lymphoma (4%),• Malignant GIST (1%) Rare Primary• Carcinoid, Angiosarcoma, Carcinosarcoma, and Squamous cell carcinoma
  3. 3. Secondary From : Melanoma , Breast(Blood born) Colon or Pancreas (Direct ext.) Ovary (By peritoneal seeding )
  4. 4. EPIDEMIOLOGY• Generally-- Disease of the elderly• Lower socioeconomic status• Blacks 2 times > whites Younger patients-- more of the diffuse variety• Large• Aggressive,• Poorly differentiated,• Sometimes infiltrating the entire stomach (linitis plastic)
  5. 5. ETIOLOGY Common in- Pernicious anemia- Blood group A -A family history of gastric cancer- Environmental factors appear more related to the intestinal form
  6. 6. Factors Increasing or Decreasing the Risk of Gastric CancerIncrease risk Decrease risk• Family history • Aspirin• Diet (high in nitrates, salt, fat) • Diet (high fresh fruit and• Familial polyposis vegetable intake)• Gastric adenomas • Vitamin C• Hereditary nonpolyposis colorectal cancer• Helicobacter pylori infection• Atrophic gastritis, intestinal metaplasia, dysplasia• Previous gastrectomy or gastrojejunostomy (>10 y ago)• Tobacco use• Ménétriers disease
  7. 7. Premalignant Conditions
  8. 8. PATHOLOGYDysplasia- Universal precursor- Gastric resection - widespread /multifocal- EMR - localized Mild dysplasia - endoscopicbiopsy/surveillance, and Helicobactereradication
  9. 9. Early Gastric CancerMucosa and submucosa, regardless of lymphnode status• 10% have lymph node metastases 70% well differentiated 30% poorly differentiated Cure rate with adequate gastric resection and lymphadenectomy - 95%
  10. 10. Types/SubTypes(Early Gastric Cancer)• Type I Exophytic lesion extending into the gastric lumen• Type II Superficial variant IIA Elevated lesions with a height no more than the thickness of the adjacent mucosa IIB Flat lesions IIC Depressed lesions with an eroded but not deeply ulcerated appearance• Type III Excavated lesions that may extend into the muscularis propria without invasion of this layer by actual cancer cells
  11. 11. Pathologic types of early gastric cancer
  12. 12. Japanese classification of early gastric cancer
  13. 13. Advanced gastric cancerInvolves the muscularisMacroscopically classified by Bormann into four typesTypes III and IV are commonly incurable
  14. 14. Gross Morphology and Histologic Subtypes Four Gross forms :• Polypoid• Fungating• Ulcerative• Scirrhous
  15. 15. Borrmann classification of advanced gastric cancer
  16. 16. First two, tumor mass is intraluminal---• Polypoid tumors are not ulcerated• Fungating tumors are elevated intraluminally, but also ulcerated Latter two , tumor mass is in the wall of the stomach---• Ulcerative tumors are self-descriptive;• Scirrhous infiltrate the entire thickness of the stomach (linitis plastica) poor prognosis, involve entire stomach
  17. 17. Important Prognostic Indicators• Lymph node involvement• Depth of tumor invasion• Tumor grade (degree of differentiation: well, moderately, poorly)
  18. 18. Histologic Classifications
  19. 19. Lauren classification• Intestinal type (53%),• Diffuse type (33%),• Unclassified (14%). The Intestinal type associated with chronic atrophic gastritis, severe intestinal metaplasia, and dysplasia, less aggressive than the diffuse type The Diffuse type of gastric cancer associated with younger patients and proximal tumors, poorly differentiated
  20. 20. Ming classification• Expanding (67%)• Infiltrative (33%)
  21. 21. World Health Organization Histologic Typing• Adenocarcinoma• Papillary adenocarcinoma• Tubular adenocarcinoma• Mucinous adenocarcinoma• ---------------------------------------• Signet-ring cell carcinoma• Adenosquamous carcinoma• Squamous cell carcinoma• Small cell carcinoma• ---------------------------------------• Undifferentiated carcinoma• Others The Japanese classification(more detailed)
  22. 22. Spread Various modes Distant spread unusual before the disease spreads locally Distant metastases uncommon in the absence of lymph node metastases
  23. 23. Direct spreadMuscularis Serosa Adjacent organs Pancreas, Colon and Liver
  24. 24. Lymphatic spread1- Permeation2- EmboliSupraclavicular nodes (Troisier’s sign).Nodal involvement does not imply systemicdissemination
  25. 25. Blood-Borne Liver Other organs including lung and boneUncommon in the absence of nodal disease
  26. 26. Transperitoneal Indicates Incurability - Ascites- Advanced palpated either abdominally or rectally as a tumour ‘shelf ’ - Ovaries (Krukenberg’s tumours)- Umbilicus (Sister Joseph’s nodule)Laparoscopy and cytology
  27. 27. TNM Staging (AJCC &IUCC)• T: Primary tumor• Tis Carcinoma in situ; intraepithelial tumor without invasion of lamina propria• T1 Tumor invades lamina propria or submucosa• T2 Tumor invades muscularis propria or subserosa• T3 Tumor penetrates serosa (visceral peritoneum) without invasion of adjacent structures• T4 Tumor invades adjacent structures
  28. 28. N: Regional lymph nodeN0 No regional lymph node metastasisN1 Metastasis in 1 to 6 regional lymph nodesN2 Metastasis in 7 to 15 lymph nodesN3 Metastasis in more than 15 regional lymphnodes
  29. 29. M: Distant metastasis• M0 No distant metastasis• M1 Distant metastasis
  30. 30. Staging------IA T1 N0 M0------IB T1 N1 M0 T2 N0 M0 ------II T1 N2 M0 T2 N1 M0 T3 N0 M0------IIIA T2 N2 M0 T3 N1 M0 T4 N0 M0------- IIIB T3 N2 M0 --------IV T4 N1–3 M0 T1–3 N3 M0 Any T Any N M1
  31. 31. CLINICAL MANIFESTATIONS - Weight loss - Anorexia / early satiety - Abdominal pain - Nausea, vomiting, bloating - Acute GI bleeding (5%) - Chronic occult blood loss is common ( iron deficiency anemia and heme-positive stool)- Dysphagia (cardia)
  32. 32. Paraneoplastic syndromes RareTrousseaus syndrome (thrombophlebitis)Acanthosis nigricans (hyperpigmentation ofthe axilla and groin)Peripheral neuropathy
  33. 33. Physical examinationFocused examination :NeckChestAbdomenRectum and pelvis
  34. 34. • Cervical• supraclavicular (on the left referred to as Virchows node)• axillary lymph nodes may be enlarged FNAC
  35. 35. - Metastatic pleural effusion- Aspiration pneumonitis- An abdominal mass indicate a large primary tumor - Liver metastases - Carcinomatosis - Krukenbergs tumor - Palpable umbilical nodule (Sister Josephs nodule) malignant ascites
  36. 36. Rectal exam• Heme-positive stool• Hard nodularity extraluminally and anteriorly Drop metastases, or rectal shelf of Blumer in the pouch of Douglas
  37. 37. DIAGNOSTIC EVALUATION Peptic ulcer / Gastric cancer clinical grounds impossible• age 45 years Endoscopy and biopsy• new onset dyspepsia• alarm symptoms Double-contrast barium• family history
  38. 38. Preoperative staging• Abdominal/Pelvic CT scanning ( contrast)• MRI• Locally EUS - enlarged (>5 mm) perigastric and celiac lymph nodes• EUS- early gastric cancer (T1) from more advanced tumors• Positron Emission Tomography Scanning(+CT)• Staging Laparoscopy and Peritoneal Cytology
  39. 39. TREATMENT• Surgical resection Curative treatment Exceptions:• cannot tolerate operation• overwhelming metastatic disease
  40. 40. Goal• R0 resection / adequate lymphadenectomy• Negative margin of at least 5 cm required• In diffuse variety, beyond 5 cm desirable• Frozen section confirmation
  41. 41. GastrectomyCurative - Primary tumor resected en blocwith adjacent involved organs (distalpancreas, transverse colon, or spleen) Palliative - indicated in incurable disease
  42. 42. Subtotal gastric resection - ligation of the left and right gastric and gastroepiploic arteries at origin - en bloc removal of the distal 75% of the stomach, 2 cm of duodenum - the greater and lesser omentum, associated lymphatic tissue• Reconstruction - Billroth II gastrojejunostomy• the spleen and pancreatic tail not removed In absence of involvement• operative mortality - 2 to 5%
  43. 43. Total gastrectomy• with Roux-en-Y esophagojejunostomy in proximal gastric adenocarcinoma• Total gastrectomy - superior functional, not oncologic, results for proximal gastric cancer
  44. 44. Extent of Lymphadenectomy• The Japanese Research Society for Gastric Cancer numbered the lymph node stations that potentially drain the stomach Generally these are grouped into• level D1 ( stations 3 to 6),• level D2 ( stations 1, 2, 7, 8, and 11) &• level D3 ( stations 9, 10, and 12) nodes D1 nodes are perigastric D2 nodes are along the hepatic and splenic arteries D3 nodes are the most distant
  45. 45. The standard operation for gastric cancer isthe D2 gastrectomy, which involves a moreextensive lymphadenectomy (removal of theD1 and D2 nodes)
  46. 46. Other treatment modalities RadiotherapyRole is controversialNumber of radiosensitive tissues in theregion of the gastric bed - limits the doseRole in the palliative treatment of painfulbony metastases
  47. 47. Chemotherapy Improves the outcome Should have chemotherapy before surgeryNumber of regimes / currently used Epirubicin, Cis-platinum & infusional 5-Fluorouracil (5-FU) or an oral analogue such as Capecitabine
  48. 48. • First line in inoperable disease• Oxaliplatin substituted for Cis-platinum ( fewer side-effects)• Second-line treatment combinations including Taxotere ↑• Chemotherapy in advanced disease is palliative