This document provides an overview of stomach cancer including its epidemiology, risk factors, pathology, clinical presentation, staging, treatment and outcomes. Some key points: - Stomach cancer is the 4th most common cancer and 2nd leading cause of cancer death worldwide. Risk factors include H. pylori infection, diet low in fruits/veggies, smoking, and family history. - Most stomach cancers are adenocarcinomas. Treatment involves surgical resection of the tumor along with lymph nodes, with or without chemotherapy or radiation before/after surgery depending on staging. - 5-year survival ranges from 71% for early stage to 4% for late stage disease. Outcomes are generally better in Asia

1. Orach Walter MBChB 3.
Cancer of the stomach

2. outline
 Anatomy/introduction
 Epidemiology
 Etiology/Risk Factors
 Pathology
 Clinical Presentation
 Preoperative Evaluation
 Staging
 Treatment
 Outcomes
 Follow up

3. anatomy

4. Arterial blood supply

5. Lymphatic drainage

6. introduction
 It’s the fourth common cancer and second leading
cause of cancer death.
 Can occur at any age but peak incidence is
between 50-70 years.
 More aggressive in younger age groups and
more common in males.
 Its more prevalent in Asia (eastern Asia) and
south America, with Japan having the highest rate
of the cancer cases.
 Its on the rise in developing countries and
reducing in the united states of America .
 Early diagnosis is the key to success

7. In the united states ;10 cases per 100,000
population per year.
In the united kingdom; 15 cases per 100,000
population per year
Eastern Europe ; 40 cases per 100,000 per year.
Japan ; 70 cases per 100,000 per year
 No available data in our setting.
Epidemiology

8. Etiology
 Unknown but several risk factors:
Aquired;
 Helicobacter pylori infection(3-6 times)
 Age
 Gender
 Diet low in fruits and vegs.
 Smoking
 Obesity
 Tobacco use

9. Genetic
 Blood Group A
 Pernicios anemia
 Menetrier disease (hypertrophic gastropathy)
 Inherited cancer syndromes eg Hereditary diffuse
gastric cancer Hereditary non-polyposis colorectal
cancer (HNPCC)
infections
 Epstein Barr Virus (EBV)
 Helico pyloric bactrtia
Cont..

10. Cont..
others
 Familial history
 Previous surgery

11. Pathology
 About 90% to 95% of cancers of the stomach are
adenocarcinomas.
Others :
 Squamous Cell Carcinoma
 Adenoacanthoma
 Carcinoid
 Gastrointestinal stromal tumors (GISTs)
 Lymphoma

12. Spread
 Lymphatic
 Blood(Liver commonest)
 Transperitoneal
 Direct

13. Clinical presentation
 Early cancer of the stomach does not cause signs
and symptoms thus making it difficult to diagnose.
 1 in 5 are diagnosed early in the USA.
 Depends on the stage of the disease at the time
of presentation. In our setting, patients present
very late.

14. Clinical presentation
They include:
 Weight loss and reduced appetite
 Epigatric pain
 Vomiting
 Abdominal mass
 Dysphagia
 Jaundice
 Ascites
 Troisier’s sign

15. Clinical presentation
 Blummer shelf (recto-vesicle metastases)
 Anaemia and cachexia
 Haematemesis/melaena
 Peritonitis(perforation)
 Metastases to the umbilicus(Sister Joseph’s
nodules)
 Krukenberg tumors
 Cutaneous metastases

16. Investigations
Endoscopy
 Esophagogastroduodenoscopy /
Imaging
 Barium meal
 EUS(endoscopy ultrasound)
 CT scan
 MRI
 PET(Positron emission tomography)
 Chest X-Ray

17. Investigations
Other investigations ..
 Complete Blood Count
 Liver Functional Tests
 Renal Functional test
 Grouping and X-matching

20. Management
 Location of the tumor
 Resectable Vs Non resectable
 Curative Vs Non curative surgery
 Lymph node clearance
 Reconstructive surgery

21. Goals of management
 Correction of anemia
 Correction of nutritional status
 Fluid and electrolyte correction
 Prophylactic antibiotics
 Cardiac and respiratory status monitering

22. Surgical Treatment
 Absence of distant metastases
 Resection margin w/ neg. microscopic
margins
 Gastric tumors char. by extensive
intramural spread
 Line of resection at least 6 cm from the
tumor mass to decrease recurrence at
anastomosis
 App surgery based on location / pattern
of spread

23. Surgical treatment
Resectable Vs unresectable
 Unresectable cancers can’t be removed
completely.
 This might be because the tumor has
grown too far into nearby organs or
lymph nodes, it has grown too close to
major blood vessels, it has spread to
distant parts of the body, or the person
is not healthy enough for surgery.

24. Surgical treatment
 Cardia / proximal ~ 35-50% of gastric
adenocarcinomas
 Proximal
 More advanced at presentation
 Curative resection is rare
 Total gastrectomy or proximal gastric resection

25. Proximal / Cardia
Proximal Gastrectomy– increased
morbidity / mortality
Buhl, et al.
Dumping, heartburn, reduced appetite
Norwegian Stomach Ca Trial
Prox. gastrectomy morbid / mortal 52% 16%
Total gastrectomy morbid / mortal 38% 8%
Total gastrectomy considered procedure
of choice for proximal gastric lesions

26. Distal tumors
 Account for ~ 35 % of all gastric cancers
 No 5-year survival difference between
subtotal vs total gastrectomy
 Subtotal appropriate if negative margins
 Recurrence vs nonrecurrence depends on
margin of 3.5 cm vs 6.5 cm

27. Endoscopic mucosal resection
 This operation is not done as much in
the United States as it is in Japan and
some other countries, where stomach
cancer is often detected early during
screening.
 If you are going to have this surgery, it
should be at a center that has
experience with this technique.

28. Lymphadenectomy
 Conventional Western lymph node
dissection during therapeutic
gastrectomy for cancer of the stomach
includes removal of the perigastric
(mostly N1) nodes only and has been
referred to as D1 lymph node dissection.

29. Lymphadenectomy
 In 1960s the Japanese surgeons first
introduced the extended
lymphadenectomy procedure (D2),
during which in addition the (N2) lymph
nodes around the coeliac axis, the left
gastric artery, the common hepatic
artery and the splenic artery as well as
those at the splenic hilus were removed

30. Lymphadenectomy
 Some also advocated the removal of
(N3) nodes around the upper abdominal
aorta (D3 lymphadenectomy), based on
the fact that 20–30% of patients with
non-early gastric cancer (>T1) have
micrometastases in those para-aortic
lymph nodes.
 Hence, D3 resection also included
nodes surrounding the superior
mesenteric artery, at the posterior
aspect of the pancreas head as well as

31. Lymphadenectomy
During the last years, some have
advocated removal of all para-aortic
lymph nodes, which was previously
referred to as D2+ or D4
lymphadenectomy

32. Lymphadenectomy
Extended Lymphadenectomy is Controversial
Japanese system
D1 – group 1 LN
D2 – groups 1 & 2
D3 – D2 plus para-aortic LN
To remove station 10 & 11 LN – splenectomy
D2 resection – partial pancreatectomy

33. Reconstruction

34. Reconstruction

35. Reconstruction

36. Palliative surgery for
unresectable
 Subtotal gastrectomy
 Gastric bypass
 Endoscopic tumor ablation
 Stent placement
 Feeding tubes(G/J tubes)

37. Post operative complications
 Leakage of the oesophago-jejunostomy
 Leakage from duodenal stump
 Biliary peritonitis
 Secondary hemorrhage
 Reduced capacity
 Diarrhoea

38. Outcomes(USA)
The 5-year survival rates by stage for stomach
cancer treated with surgery are as follows:
 Stage IA 71%
 Stage IB 57%
 Stage IIA 46%
 Stage IIB 33%
 Stage IIIA 20%
 Stage IIIB 14%
 Stage IIIC 9%
 Stage IV 4%
 The overall 5-year relative survival rate of all
people with stomach cancer in the United States
is about 27%.
Japan(NCCH)
I 91.2%
II 80.9%
III 54.7%
IV 9.4%
TOTAL 71.4%

39. Chemotherapy
Can be used as: neoadjuvant, adjuvant, Primary.
 5-FU (fluorouracil), often given along with
leucovorin (folinic acid)
 Capecitabine
 Carboplatin
 Cisplatin
 Docetaxel
 Epirubicin
 Irinotecan
 Oxaliplatin
 Paclitaxel

40. Chemotherapy
Common chemo combinations include:
 ECF (epirubicin, cisplatin, and 5-FU),which may
be given before and after surgery
 Docetaxel or paclitaxel plus either 5-FU or
capecitabine, combined with radiation as
treatment before surgery
 Cisplatin plus either 5-FU or capecitabine,
combined with radiation as treatment before
surgery
 Paclitaxel and carboplatin, combined with
radiation as treatment before surgery

41. Targeted therapies
Trastuzumab
 About 1 out of 5 of stomach cancers has too
much of a growth-promoting protein called
HER2/neu (or just HER2) on the surface of the
cancer cells.
 Tumors with increased levels of HER2 are called
HER2-positive.