This document discusses gastric cancer staging, prognosis, and treatment options. It outlines the TNM staging system used by the International Union Against Cancer, describing tumor size, lymph node involvement, and metastasis. Treatment may include surgery such as gastrectomy, chemotherapy, and radiotherapy. Palliative procedures are used for inoperable cases. Risk factors, screening, and complications are also summarized.

1. Aswathi Raveendran U.V

2. Staging
Prognosis
Treatment plans
Patient preparation
Surgery, Chemotherapy, Radiotherapy
Palliative Procedures
Screening

3. *
*International Union Against Cancer
*Union Internationale Contre le Cancer
* T N M Staging

4. *
*T1 – involves lamina propria & submucosa
T1a – lamina propria
T1b – submucosa
*T2 – tumour invades muscularis propria
*T3 – tumour involves subserosa
*T4a – tumour perforates serosa
*T4b – tumour invades adjacent organs

5. *
*N0 - No lymph nodes
*N1 - 1-2 regional nodes
*N2 - 3-6 regional nodes
*N3
N3a - 7-15 regional nodes
N3b - >15 regional nodes

6. *
*M0 - No distant metastases
*M1 - distant metastases
(peritoneum &distant lymph nodes)

7. *
*Stage IA - T1 N0 M0
IB - T1 N1 M0 / T2 N0 M0
*Stage IIA - T1 N2 M0/ T2 N1 M0 / T3 N0 M0
*Stage IIB – T1 N3 M0/ T2 N2 M0 / T3 N1 M0 / T4a N0 M0
*Stage IIIA -T2 N3 M0 / T3 N2 M0 / T4a N1 M0
*Stage IIIB -T3 N3 M0 / T4a N2 M0 / T4b N0 -1 M0
*Stage IIIC –T4a N3 M0 / T4b N2-3 M0
*Stage IV - Any T/ Any N/ M 1

8. *
*Lymph node involvement – four or more
*Depth of tumor invasion - serosa
*Differentiation of tumor
*5year survival rates following curative surgery
*25-30% in the west
*50-75% in Japan

9. *
*Diagnostic laparoscopy ---staging
*Peritoneal metastasis
*Laparoscopic US --- liver metastasis
*Adjacent organ invasion
*Guided biopsies
*Peritoneal lavage and cytology

10. *
*Positive cytology in peritoneal wash
*Peritoneal deposits
*Posterior fixation
*Fixed celiac nodes
*Para-aortic nodes
*Liver metastasis

11. *
*Hematogenous metastasis
*Involvement of distant peritoneum
*N4 nodal disease
*Fixation to structures that cannot be
removed

12. *
*Early gastric cancer, Stage T1N0--- EMR
*Operable cases
*Radical Gastrectomy
*Neoadjuvant chemotherapy
*Advanced stages – chemotherapy / radiotherapy
*Inoperable cases: Palliation

13. *
*The only curative treatment
*Palliative
*Most accurate staging

14. *
*R0 resection
*All margins negative
*Adequate lymphadenectomy
*At least 5cm negative margin

15. *
*Correction of anemia
*Correction of nutritional status
*Fluid and electrolytes
*Cardiac, respiratory and renal status
*Adequate blood
*Pre operative stomach wash
*Prophylactic antibiotics

16. *
*Early gastric cancer
*Tumor less than 2cm
*Elevated well differentiated tumors
*Without nodal involvement

19. *

20. *
• Standard operation for
gastric cancer
• Distal tumors
• Midline vertical incision

21. *
• Ligation of left and right gastric and gastro
epiploic arteries
• En bloc removal of 75% of stomach
• Pylorus
• 2cm of duodenum
• Greater and lesser omentum
• All associated lymphatic tissue

23. *
Billroth II
Gastro-jejunostomy

24. *
*Proximal gastric adenocarcinoma, linitis plastica
*stomach removed en bloc + greater and lesser
omentum
*Same survival results compared to
*Higher complication rate subtotal
*Reconstruction :
• Roux-en-Y esophago-jejunostomy
• At least 50 cm long loop

25. *Upper midline incision
*Stomach + GO + LO
*Transverse colon
seperated from G O
*Subpyloric LN
dissection
*D1 divided
*Hepatic LN dissection
*Clear hepatic artery
*Supra pyloric LN
*Rt.gastric artery taken
on hepatic artery
*LN dissection to origin
of Lt.gastric artery
*Flush ligation of LGA
*Continue LN dissection
along splenic artery
*Separate stomach from
spleen
*Divide oesophagus

27. *
Cesar Roux

29. *
*Japanese
*Level N1 : Station 3-6
Within 3 cm of the tumor
*Level N2 : Station 1,2,7,8,11
Along hepatic and splenic arteries
*Level N3 : Station9,10,12
Most distant
*D1 resection : removes N1 nodes + tumor
*D2 resection : D1 + N2 nodes + peritoneal layer over
pancreas and mesocolon

31. *

32. *

33. *

34. *
*Leakage of oesophago-jejunostomy
*Leakage from duodenal stump
*Para-duodenal collections
*Biliary peritonitis
*Secondary hemorrhage
LATE COMPLICATIONS:
*Reduced capacity
*Dumping
*Diarrhea
*Nutritional deficiencies

35. *
*Palliative partial gastrectomy
*Palliative anterior gastro-jejunostomy with jj
*Palliative chemotherapy
*Endoscopic stenting/dilatation
*Laser recanalization

37. *Gastric cancer responds well to combination
cytotoxic chemotherapy
*Neo adjuvant therapy improves outcome
*First line treatment in inoperable disease
*Palliative in advanced disease
*Trantuzumab – in HER2 positive gastric cancer

38. *
*Down staging of disease --- increase resectability
*Determine sensitivity to chemotherapy
*Decreases micro-metastatic burden
* Epirubicin + cis-platinum+ infusional 5-FU/
capecitabine

39. *
*Advanced stages
*Radiosensitive tissues in gastric bed !
*4500cGy adjuvant therapy
*Palliative treatment of painful bony metastasis

40. *
*Effective in high risk population
*Periodic endoscopy and biopsy
Familial adenomatous polyposis
HNPCC
Gastric adenoma
Menetriers disease
• hypoproteinemic hypertrophic gastropathy
Intestinal metaplasia/ dysplasia

41. Thank You…