1. Carcinoma of the stomach is a major cause of cancer mortality worldwide, with generally poor prognosis and 5-10% cure rates. Better results are seen in Japan where it is more common. 2. Risk factors for gastric cancer include H. pylori infection, pernicious anemia, ulcer surgery, smoking, diet high in salt/low in antioxidants, and genetic factors. 3. Gastric cancer is classified into intestinal and diffuse subtypes, with the latter often showing signet ring cells. Recognition of molecular subtypes is leading to targeted therapies.

1. CARCINOMA STOMACH
DR ARUNABHA SINHA

2. • Carcinoma stomach is the captain of men of death.
• Carcinoma of the stomach is a major cause of cancer
mortality worldwide. Its prognosis tends to be poor, with cure
rates little better than 5–10%.
• But better results are obtained in Japan, where the disease
is common.
GASTRIC CANCER

3. Carcinoma stomach
1.The presence of a gastric adenomatous polyp is a marker
of increased risk for the development of cancer in the
remaining gastric mucosa.
2.The extent of gastric resection is determined by the need
to obtain a resection margin free of microscopic disease.
3.Examination of minimum of 15 nodes is suggested for
adeqate staging.

4. Multimodality treatment should be the standard of care for
locally advanced resectable gastric cancer.
Low grade gastric MALT lymphomas are effectively
treated with erradication of H.pylori infection alone.
95% of gastrointestinal stromal tumors (GISTs) express
the KIT antigen, which is an important molecular target for
medical therapy.

5. Risk Factors for Gastric Cancer:
1.H. pylori infection.
2.Pernicious anaemia and gastric atrophy.
3.Ulcer surgery.
4.Cigarette smoking and dust ingestion from a
variety of industrial processes.
5.Diet, Excessive salt intake, deficiency of antioxidants and
exposure to N-nitroso compounds.

6. 6.environmental.
7.Obesity and higher socioeconomic status in proximal gastric
cancers.
8.Genetic factors:
A range of mutations in genes related to genome integrity e.g.
BRCA2 , TP53 , AR1D1 A, chromatin remodelling e.g. SMARCAI ,
CHD3&4 , cell-cell adhesion and motility e.g. RHOA, CDH 1 have
been described.

7. The most useful clinicopathological classification of gastric
cancer is the Lauren classification. In this system there
are principally two forms of gastric cancer:
1.intestinal gastric cancer and
2.diffuse gastric cancer (often with signet ring cells).

8. The Cancer Genome Atlas (TCGA) group described four
molecular subtypes of gastric cancer: Epstein–Barr virus
positive, microsatellite unstable, genomically stable and
chromosomal instability. Recognition of these subgroups and
their underlying common gene mutations and driver events is
leading to the development of targeted therapies, including
immunotherapies.

9. CLINICAL PRESENTATION
Signs and Symptoms of Gastric Cancer
The signs and symptoms of gastric cancer are nonspecific and
similar to individuals in the general population. They include
dyspepsia, fatigue, and malaise among others. Other, more
concerning symptoms that are often referred to as alarm
symptoms, include weight loss, dysphagia, persistent vomiting,
gastrointestinal bleeding, anemia, and a palpable abdominal
mass.

10. Abdominal distension and ascites is a finding concerning for
peritoneal carcinomatosis, as is the finding of a palpable nodule
at the umbilicus (the Sister Mary Joseph node). Rectal
examination may identify an anterior mass in the pouch of
Douglas related to peritoneal carcinomatosis and drop metastasis
to the pelvis (the Blumer shelf). In advanced disease, pallor
related to anemia and evidence of weight loss may be present.

11. The features of advanced gastric cancer are usually obvious. In
patients with advanced disease, a palpable supraclavicular mass,
generally on the left side, can be a sign of distant nodal
metastasis (the Virchow node). A bulky antral tumor or extensive
nodal metastases will occasionally lead to jaundice from bile duct
obstruction in the hepatoduodenal ligament. A palpable abdominal
mass may be found, sometimes from a bulky primary tumor, but
more commonly from omental caking with metastases.

12. In advanced cancer, early satiety, bloating, distension and
vomiting may occur. The tumor frequently bleeds, resulting in
iron deficiency anemia. Obstruction leads to dysphagia,
epigastric fullness or vomiting. Weight loss can be profound.
With pyloric involvement the presentation may be of gastric
outlet obstruction.

13. GASTRIC OUTLET OBSTRUCTION
● The two common causes of gastric outlet obstruction
are gastric cancer and pyloric stenosis secondary to
peptic ulceration. Previously, the latter was more
common .

14. Metabolic effects
• These are most interesting, as the consequences of
benign pyloric stenosis are unique. The vomiting of
hydrochloric acid results in hypochloraemic alkalosis.
Initially the sodium and potassium may be relatively
normal. Initially, the urine has a low chloride and high
bicarbonate content.This bicarbonate is excreted along
with sodium, and so with time the patient becomes
progressively hyponatraemic and more profoundly
dehydrated.

15. • Because of the dehydration, a phase of sodium
retention follows and potassium and hydrogen are
excreted in preference.
• This results in the urine becoming paradoxically
acidic and hypokalaemia ensues. Alkalosis leads to
a lowering in the circulating ionised calcium, and
tetany can occur.

16. Non-metastatic effects of malignancy are seen,
particularly thrombophlebitis (Trousseau’s sign) and deep
venous thrombosis. These features result from the effects
of the tumor on thrombotic and hemostatic mechanisms.

21. Staging
• The International Union Against Cancer (UICC) staging
system. Important changes have been made in the
seventh edition of the TNM staging system that are worthy
of discussion. In an attempt to reflect the current staging
system.

24. Spread of carcinoma of the stomach
1.Direct spread
The tumour penetrates the muscularis, serosa, ultimately adjacent
organs such as the pancreas, colon and liver.
2.Lymphatic spread
This is by both permeation and emboli to the afected tiers of
nodes. This may be extensive, the tumor even appearing in the
supraclavicular nodes (Troisier’s sign). Unlike malignancies such
as breast cancer, nodal involvement does not imply systemic

25. 3.Blood-borne metastases
This occurs frst to the liver and subsequently to other organs,
including lung and bone. This is uncommon in the absence of
nodal disease.
4.Transperitoneal spread
This is a common mode of spread once the tumour has reached
the serosa of the stomach and indicates incurability. Tumors can
manifest anywhere in the peritoneal cavity and commonly give
rise to ascites.

26. Advanced peritoneal disease may be palpated either
abdominally or rectally as a tumor ‘shelf ’. The ovaries may
sometimes be the sole site of transcoelomic spread
(Krukenberg’s tumours). Tumor may spread via the abdominal
cavity to the umbilicus (Sister Joseph’s nodule).
Transperitoneal spread of gastric cancer can be detected most
effectively by laparoscopy and cytology.

27. Operative treatment
Total gastrectomy
Subtotal gastrectomy
Palliative surgery
Most operable patients should have neoadjuvant
chemotherapy as this improve survival.

33. Complications of gastrectomy
1. Leakage of the oesophagojejunostomy
2. Leakage from the duodenal stump can occur.
3. Paraduodenal collections
4.Biliary peritonitis
5.Presence of septic collections
6.Nutritional deficiencies
Long term complications are less common

34. Other treatment modalities
Radiotherapy
The routine use of radiotherapy is controversial as the results
of clinical trials are inconclusive.But Radiotherapy has a role in
the palliative treatment of painful bony metastases
Chemotherapy
Gastric cancer may respond well to combination cytotoxic
chemotherapy and neoadjuvant chemotherapy improves the
outcome following surgery.

35. Best results are currently obtained using a combination of
epirubacin , cis-platinum and infusional 5-FU or oral
capecitahine.
Second - line treatment using combinations which include
taxotere are increasingly being used.
trastuzumab( Herceptin ) offer potential advantages to survival
in the minority of patients ( < 20% ) with HER 2-positive gastric

36. Squamous cell cancer is endemic in the Transkei region of
South Africa and in the Asian ‘cancer belt’, which extends
across the middle of Asia from the shores of the Caspian
Sea (in northern Iran) to China. The highest incidence in
the world is in Linxian in Henan province in China, where it
is the most common single cause of death, with more than
100 cases per 100 000 population per annum.

37. GASTROINTESTINAL STROMAL TUMOURS
●Gastrointestinal stromal tumours (GISTs) may arise
in any part of the gastrointestinal tract but 50% will
be found in the stomach. Previously named
leiomyoma and leiomyosarcoma, the term GIST is
now used, recognising their particular distinct
phenotype.

38. ●They are tumours of mesenchymal origin and are
observed equally commonly in males and females.
The tumours are universally associated with a
mutation in the tyrosine kinase c-kit oncogene. These
tumours are sensitive to the tyrosine kinase
antagonist imatinib, and an 80% objective response
rate can be observed.

39. ●Tumours with mutations in exon 11 of c-kit are
particularly sensitive to this drug. The biological
behaviour of these tumours is unpredictable but
size and mitotic index are the best predictors of
metastasis. Peritoneal and liver metastases are
most common but spread to lymph nodes is
extremely rare.

40. ●Tumours over 5 cm in diameter should be considered
to have metastatic potential. If easily resectable,
surgery is the primary mode of treatment. Smaller
tumours can be treated by wedge excision.

42. GASTRIC LYMPHOMA
It is first important to distinguish primary gastric lymphoma from
involvement of the stomach in a generalised lymphomatous
process. Following diagnosis, adequate staging is necessary,
primarily to establish whether the lesion is a primary gastric lym -
phoma or part of a more generalised process. CT scans of the
chest and abdomen and bone marrow aspirate are required, as
well as a full blood count.

43. Although the treatment of primary gastric lymphoma is
somewhat controversial, it seems most appropriate to use
surgery alone for the localised disease process.
Chemotherapy alone is appropriate for patients with systemic
disease.

45. Neuroendocrine tumours:
A number of neuroendocrine neoplasms occur in the duodenum.
It is a common site for primary gastrinoma (Zollinger– Ellison
syndrome).
The tumours are most commonly found in the ‘gastrinoma
triangle’ (Passaro) defined by the junction of the cystic duct and
common bile duct superiorly, the junction of the second and third
parts of the duodenum inferiorly, and the junction of the neck and
body of the pancreas medially (essentially the superior
mesenteric artery).

46. Duodenal obstruction in the adult is usually due to
malignancy, and cancer of the pancreas is the most
common cause. About one-fifth of patients with
pancreatic cancer treated with endoscopic stenting
will develop obstruction. Treatment is usually by
gastroenterostomy.
DUODENAL OBSTRUCTION

47. Acute gastric dilatation
●This condition usually occurs in association with pyloroduodenal
disorders or postsurgery without nasogastric suction. The
stomach, which may also be atonic, dilates enormously. Often
the patient is also dehydrated and has electrolyte disturbances.
● Failure to treat this condition can result in a sudden massive
vomit with aspiration into the lungs. The treatment is nasogastric
suction, with a large-bore tube, fluid replacement and treatment
of the underlying condition.

48. Trichobezoar (hair balls)
●Are unusual and are virtually exclusively found in female
psychiatric patients, often young. It is caused by the
pathological ingestion of hair, which remains undigested in
the stomach.
● The diagnosis is made easily at endoscopy or, indeed, from
a plain radiograph. Treatment consists of removal of the
bezoar, which may require open surgical treatment.

50. Foreign bodies in the stomach
●A variety of ingested foreign bodies reach the stomach, and very
often these can be seen on a plain radiograph. If possible, they
should be removed endoscopically but, if not, most can be left to
pass normally.

51. THANK YOU