This document provides tips and guidelines for using a PowerPoint presentation on stomach cancer. It includes 12 slides on topics like introduction/history, etiology, anatomy, pathology, staging, classification, investigations, management, prevention, and guidelines. The document recommends using blank slides to engage students in an active learning session by asking them questions before presenting content. It also notes the presentation is good for self-study and refers the user to notes for bibliography citations.

1. Tips on using my ppt.
1. You can freely download, edit, modify and put your
name etc.
2. Don’t be concerned about number of slides. Half the
slides are blanks except for the title.
3. First show the blank slides (eg. Aetiology ) > Ask
students what they already know about ethology of
today's topic. > Then show next slide which enumerates
aetiologies.
4. At the end rerun the show – show blank> ask questions >
show next slide.
5. This will be an ACTIVE LEARNING SESSION x
three revisions.
6. Good for self study also.
7. See notes for bibliography.

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.

90. Get this ppt in mobile
1. Download Microsoft
PowerPoint from play
store.
2. Open Google assistant
3. Open Google lens.
4. Scan qr code from
next slide.

92. Get this ppt in mobile
1. Download Microsoft
PowerPoint from play
store.
2. Open Google assistant
3. Open Google lens.
4. Scan qr code from
next slide.

93. Get this ppt in mobile

94. Get my ppt collection
• https://www.slideshare.net/drpradeeppande/
edit_my_uploads
• https://www.dropbox.com/sh/x600md3cvj8
5woy/AACVMHuQtvHvl_K8ehc3ltkEa?dl
=0
• https://www.facebook.com/doctorpradeeppa
nde/?ref=pages_you_manage