Carcinoma stomach management

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Management of CA Stomach

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Carcinoma stomach management

  1. 1. Carcinoma Stomach ( Gastric Carcinoma ) Management - Shriyans Jain
  2. 2. When do you suspect ? • Clinical Features – Symptoms suggestive of a malignancy ? – Signs ? Differential diagnosis ?
  3. 3. Differentials • Acid peptic disease, pyloric stenosis with gastric outlet obstruction. •Gastritis •Pancreatic mass •Transverse Colon mass
  4. 4. Investigations • Flexible Endoscopy • Contrast radiology • Ultrasonography ( Endoscopic USG – EUS ) • CT Scan and MRI • PET – CT • Laparoscopy
  5. 5. To confirm the diagnosis • Flexible Upper GI Endoscopy with directed biopsy followed by histopathological examination of the sample.
  6. 6. Flexible Upper GI Endoscopy EGD (esophago gastro duodenoscopy) • Visual examination of the upper intestinal tract using a lighted, flexible fiberoptic or video endoscope • Gold standard • More sensitive than conventional radiology ( 95% accuracy ) • Advantages – Outpatient procedure – No radiation Exposure – Targeted biopsy from the lesion can be taken at the same setting. – Diagnosis can be made more accurately
  7. 7. Indications • Ulcers in the upper GI tract • Tumors of the stomach or esophagus • Severe/Persistent Dysphgia • Undiagnosed Upper abdominal pain or indigestion • Intestinal bleeding • Esophagitis and heartburn – unresponsive to medical therapy • Gastritis
  8. 8. Contraindications • Shock • Acute MI • Peritonitis • Acute perforation • Corrosive injuries of Oesophagus
  9. 9. Gastric Carcinoma – Intestinal Type Gastric Carcinoma – Diffuse Type
  10. 10. Contrast Radiology • Single Contrast/ Double Contrast • Barium Meal • Advantages – Sensitivity comparable to endoscopy – Non Invasive procedure
  11. 11. Carcinoma of the gastric antrumStomach – Normal Duble contrast barium study
  12. 12. Gastric Carcinoma of the body and Carcinoma along the greater curvature proximal antrum ( Ulcerative lesion with filling defect ) (Multiple small ulcerations )
  13. 13. Findings in Carcinoma Stomach • Irregular filling defect • Loss of rugosity • Delayed emptying • Dilatation of stomach in carcinoma pylorus • Decreased stomach capacity in linitis plastica • Carmanns meniscus sign
  14. 14. Ultrasonography • Endoscopic / Endoluminal Ultrasound is useful to detect the involvement of layers of the stomach, nodal status and to differentiate early from advanced cancer. • Excellent at determining the T- Stage ( 90% ) • High frequency probes used to differentiate T1-2 stage • Nodal status can also be assessed • Limited use in advanced disease
  15. 15. The white arrow indicates the tumour invasion The black arrow indicares the muscularis propria A – TI stage – Tumour localized to the mucosa and sub mucosa B – T2 stage – Tumour invades the muscularis propria C – T3 stage – Tumour invades subserosa and abuts the surrounding structures ( here Aorta )
  16. 16. Chest X-ray • Look for – Lung metastases – Pleural Effusion USG abdomen • Liver metastases
  17. 17. Computed tomography and MRI • Every patient with a histological diagnosis of gastric Carcinoma should undergo a Ct of the chest and abdomen. • Provides information about – M stage ( Liver, Lung, Peritoneum and distant nodes ) – T4 stage ( involvement of the adjacent structures )
  18. 18. Localized versus Diffuse thickening
  19. 19. Secondaries from Carcinoma Stomach in the Liver and the Lung
  20. 20. Laproscopy • To stage the disease especially in locally advanced tumours – Peritoneal secondaries – Occult metastases – Organ invasion – Peritoneal lavage for cytology – Biopsy of peritoneum and nodes
  21. 21. Signs of inoperability • Peritoneal deposits • Fixity • Liver secondaries • Fixed iliac nodes • Para aortic nodes • Ascitic fluid positivity • Sister Mary Joseph Nodule • Left axillary lymph node secondaries
  22. 22. Other tests • Left Supraclavicular Node biopsy • Tetracycline flourescence test • CA 72-4 in relapse, CEA, CA 19-9, CA 12-5 • Combined PET – CT • Sentinel Node biopsy • HB, Hematocrit, LFT, PT
  23. 23. Treatment
  24. 24. Multidisciplinary Team • Surgery • Chemotherapy • Immunotherapy • Radiotherapy • Oncology and • Palliative Care
  25. 25. Goal of Treatment • Resection of all tumor • All margins (proximal, distal, and radial) should be negative and an adequate lymphadenectomy performed • Negative margin of at least 5 cm
  26. 26. Lymph node Stations Japanese Research Society of Gastric Cancer
  27. 27. • 1 Right paracardial LN • 2 Left paracardial LN • 3 LN along the lesser curvature • 4sa LN along the short gastric vessels • 4sb LN along the left gastroepiploic vessels • 4d LN along the right gastroepiploic vessels • 5 Suprapyloric LN • 6 Infrapyloric LN N 1 Group ( First tier of lymph nodes )
  28. 28. • 7 LN along the left gastric artery • 8a LN along the common hepatic artery (Anterosuperior group) • 8p LN along the common hepatic artery(Posterior group) • 9 LN around the celiac artery • 10 LN at the splenic hilum • 11p LN along the proximal splenic artery • 11d LN along the distal splenic artery • 12a LN in the hepatoduodenal ligament (along the hepatic artery) • 12b LN in the hepatoduodenal ligament (along the bile duct) • 12p LN in the hepatoduodenal ligament (behind the portal vein) N 2 Group (Second tier of lymph nodes )
  29. 29. • 13 LN on the posterior surface of the pancreatic head • 14v LN along the superior mesenteric vein • 14a LN along the superior mesenteric artery • 15 LN along the middle colic vessels • 16a1 LN in the aortic hiatus • 16a2 LN around the abdominal aorta (from the upper margin of the celiac trunk to the lower margin of the left renal vein) • 16b1 LN around the abdominal aorta (from the lower margin of the left renal vein to the upper margin of the inferior mesenteric artery) • 16b2 LN around the abdominal aorta (from the upper margin of the inferior mesenteric artery to the aortic bifurcation) • 17 LN on the anterior surface of the pancreatic head • 18 LN along the inferior margin of the pancreas
  30. 30. • 19 Infradiaphragmatic LN • 20 LN in the esophageal hiatus of the diaphragm • 110 Paraesophageal LN in the lower thorax • 111 Supradiaphragmatic LN • 112 Posterior mediastinal LN
  31. 31. Surgical Resection of the tumour • Based on the TNM staging – Patients with early gastric cancer should undergo a subtotal or total D2 gastrectomy – Patients with advanced disease should undergo multi-modality treatment with neoadjuvant chemotherapy and surgery
  32. 32. Based on site of the tumour • Pylorus Lower radical Gastrectomy ( proximal 5cm clearance with removal of greater omentum , lesser omentum, lymph nodes, spleen, tale of pancreas ) • OG junction Upper Radical Gastrectomy ( Total Gastrectomy is ideal ) (removal of greater omentum , lesser omentum, lymph nodes, spleen, tale of pancreas )
  33. 33. Sub-Total Gastrectomy
  34. 34. • Linitis Plastica Total Gastrectomy D2 Gastrectomy – Removal of stomach with growth , both the omentum, omental bursa, anterior layer of mesocolon, anterior pancreatic capsule, D2 lymphadenectomy ) Distal Clearance towards duodenum is 1cm from the tumour end
  35. 35. Lymph node dissection • D0 No dissection or incomplete dissection of the Group 1 nodes • DI Group 1 lymph nodes (LN) • D2 D1 + Group 2 LN • D3 D2 + Group 3 LN • D4 D3 + para-aortic nodes
  36. 36. Reconstruction procedures • In case of sub total or partial gastrectomy, Billroth II Anastomosis may be tried.
  37. 37. Roux-en-Y Oesophagojejunostomy • Bypasses the stomach • Done in cases of subtotal or total gastrectomy
  38. 38. Post op complications Early complications • Paralytic ileus. • Leakage from suture line. • Leakage from duodenal stump. • Acute Cholycystitis, Pancreatitis • Stomal obstruction.
  39. 39. TitleLate complications • Early Dumping syndrome • Late dumping syndrome. • Bilious vomiting. • Gastric stump cancer • Vit B12 deficiency • Osteoporosis
  40. 40. Adjuvant Therapy • Rationale behind radiotherapy is to provide additional local-regional tumor control. • Adjuvant chemotherapy is used either as a radiosensitizer or as definitive treatment for presumed systemic metastases.
  41. 41. Adjuvant Radiotherapy • lower rates of local recurrence in patients who received postoperative radiotherapy than in those who underwent surgery alone (British stomach cancer study group) • Improved survival (mayo clinic randomized patients)
  42. 42. Intra operative radiotherapy • allows for a high dose to be given in a single fraction while in the operating room so that other critical structures can be avoided. • Stage 3 and 4 • Median survival (21 months vs 10 months ) with IORT
  43. 43. Adjuvant Chemotherapy • No consistent survival benefit. • Epirubicin . 5 florouracil ,cis platinium (ECF) • Combination of chemoradio therapy has better outcome
  44. 44. Neo adjuvant chemotherapy • downstaging of disease to increase resectability, • decrease micrometastatic disease burden prior to surgery • allow patient tolerability prior to surgery • determine chemotherapy sensitivity • reduce the rate of local and distant recurrences, and ultimately improve survival.
  45. 45. Palliative Care • radiotherapy provides relief from bleeding, obstruction, and pain in 50-75% • wide local excision, partial gastrectomy, total gastrectomy, simple laparotomy, gastrointestinal anastomosis, and bypass for food intake or pain relief
  46. 46. Summary
  47. 47. Prognostic Factors • Early vs advanced • Histological grading • Staging • Gross types • Lymph node status • Liver secondaries • Serosal involvement • Diffuse vs intestinal • Ascites • Response to treatment
  48. 48. Prognosis Stage 5 year Survival (%) T1N0M0 95+ T1N1M0 70 - 80 T2N1M0 45 - 50 T3N2M0 15 - 25 M1 0 - 10
  49. 49. Thank You

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