- Gastric cancer is the 4th most common cancer and the 2nd leading cause of cancer death worldwide, except in Japan where aggressive screening and treatment programs have improved outcomes. - Risk factors include smoked/salted foods, H. pylori infection, atrophic gastritis, benign gastric ulcers, and certain genetic syndromes. Clinical presentation can include vague dyspepsia, weight loss, anemia, abdominal mass, or metastatic signs. Diagnosis involves endoscopy with biopsy. - Investigation also includes blood tests, tumor markers, imaging like CT or ultrasound to stage the cancer. Surgery is the main treatment and may involve subtotal or total gastrectomy, with reconstruction depending on

1. Gastric cancer
clinical evaluation
Omar Zohry

2. Introduction
• gastric cancer is the 4th most common cancer type .
• the 2nd leading cause of cancer death.
• Except in JAPAN.
• active screening programme resulting in earlier diagnosis and an
aggressive surgical approach designed to reduce loco-regional
recurrence in gastric bed.

3. Risk factors
• Smoked, salted foods
• Tobacco
• Alcohol
• H pylori infection
• EBV virus.
• Atrophic gastritis ,achlorhydria ,pernicious anemia
• Benign gastric ulcers
• Previous gastric operations

4. Genetic risk factors
• Positive family history of gastric cancer
• Genetic cancer syndromes as
HNPCRC
LYNCH SYNDROME
PEUTZ JEGHERS SYNDROME

5. CLINICAL FEATURES
• VAGUE
• 1. Dyspepsia group:
A person above 40 years who starts to complain of new dyspepsia should be fully
investigated for possibility of
stomach cancer.
It differs from chronic gastric ulcer in:
The patient has anorexia and vague sense of discomfort after meals.
Nausea and early satiety are common.
Epigastric pain may occur and in late cases may be severe and continuous.
Vomiting does not relieve pain.
No periodicity (shorter duration with persistent symptoms)

6. • 2. Insidious group (Anorexia, Asthenia, Anaemia):
It is characterized by 3A:
1. Anorexia (→ loss of weight).
2. Asthenia (→ wasting and weakness).
3. Anemia (→ pallor and easy fatigability).
Anaemia in elderly should always raise
possibility of malignancy, stomach being one
of the commonest to
cause it.

7. • 3. Mass group:
An epigastric mass (for D.D.) with NO other manifestations.
The mass is hard, nodular, and mobile but later becomes fixed.
About 30% of patients presenting in this way will be found to
harbour inoperable carcinoma on exploration.

8. • 4. Obstructive group:
Carcinoma occurring at one end of stomach causes obstructive
symptoms and will therefore usually present
early.
At the cardia → dysphagia
At the pylorus → pyloric obstruction

9. • 5. Metastatic (Silent or Latent) group:
Hard irregular liver
Jaundice
Malignant ascites
An enlarged left supraclavicular lymph node (Virchow's node)
"Troisier's sign"
An enlarged left axillary lymph node (Irish node).
Blumer’s shelf nodules or Krukenberg tumors (on rectal or pelvic
exams)
Periumbilical lymphadenopathy or peritoneal metastases (Sister Mary
Joseph's node)
All of which are signs of inoperability.

11. • 6. Other presentations:
Hematemesis and melena are uncommon presentations while
perforation is still rare.
A patient known to have gastric peptic ulcer who becomes
refractory to treatment.
Para-neoplastic syndromes e.g.
o Superficial thrombo-phlebitis migrans (Trousseau's sign)
o Acanthosis nigricans (hyper-pigmentation of axilla and groin)
o Peripheral neuropathy

12. DD
• Causes of dyspepsia e.g. biliary
Causes of mass in the epigastrium e.g.
o Gastric tumors
o Transverse colon cancer, intussusception
o Small intestine lymphoma, intussusception
o Lt. lobe of liver tumor or cyst
o Pancreatic mass and pancreatic pseudo-cyst
o Retroperitoneal mass
o Aortic aneurysm
o Para-aortic lymph nodes

13. HOW TO INVESTIGATE
• . Laboratory Investigations
Blood picture may reveal micro or macrocytic anemia.
Liver function tests to detect liver affection.
Renal function tests to detect electrolyte disturbances 2ry to
gastric outlet obstruction.
ESR (Increased in 70%)
Occult blood in stools (+ ve in 80% of cases)

14. • Serological Tumor markers
(CEA, CA-19-9, CA-125, and CA-72-4)

15. • Upper GI Endoscopy and biopsy
• It is the gold standard for diagnosis of gastric malignancy.
It has advantage of directly viewing tumor from which multiple
biopsies should be taken.
Endoscopy can detect tumors at earlier stage than can radiology.

16. • Air-contrast Barium meal
.
Cauliflower-like lesion will appear as persistent irregular filling defect.
Malignant ulcer will appear as ulcer niche outside the ulcer bearing area.
In linitis plastica, there will be marked narrowing of stomach lumen but flow of barium is not interrupted.
It may show malignant pyloric obstruction (Soup dish appearance).
The malignant ulcer can be differentiated from chronic GU by being:
a) > one inch in diameter.
b) The site is NOT in ulcer-bearing area.
c) Prominent rim of radiolucency surrounding the ulcer caused by heaped up edges of tumor (Carman's
meniscus sign).
d) Absence of tenderness on palpation under screen.

17. • The malignant ulcer can be differentiated from chronic GU by
being:
a) > one inch in diameter.
b) The site is NOT in ulcer-bearing area.
C) Absence of tenderness on palpation under screen

18. • abdominal ultrasound
It is essential for detection of liver secondaries.
Its role in assessing lymph node involvement is less important.
• Abdominopelvic CT scan with IV & oral contrast
It is more accurate for detection of para-aortic L.N. involvement than
sonogram and may be helpful in pre-
operative staging of disease.
Hydro-helical CT scanning with patient in prone position is very used
for assessing extent of involvement of
stomach wall and posterior fixation (usually to pancreas)

19. • Endoscopic ultrasound (EUS)
The best way to stage tumor locally is via EUS
It gives fairly accurate (80%) information about depth of tumor
penetration into gastric wall, and can usually
show enlarged (>5 mm) perigastric and celiac lymph nodes.
Needle biopsy can be done under EUS guidance

20. • Staging Laparoscopy and Peritoneal Cytology
A quick laparoscopic examination can occasionally reveal small
peritoneal implants or liver metastases that were not detected on
preoperative imaging studies.
This may change operative plan and avoid major but futile
surgical procedure in some patients (e.g. high risk for surgery or
impressive carcinomatosis).

21. MANAGEMENT
• 1. For tumors in the middle or distal stomach:
Radical distal (subtotal) gastrectomy is the standard operation.
• 2. For tumors in the proximal stomach:
Radical total gastrectomy is the standard operation.
• 3. For proximal gastric tumor invading GEJ:
Gastrectomy with lower oesophagectomy is recommended.
•
o If tumor invading less than 2 cm into esophagus, total abdominal approach with
transhiatal resection of lower
oesophagus and lower mediastinal lymph nodes can be achieved.
o If tumor extending more than 2 cm into esophagus, patients usually require left
thoraco-laparotomy

22. RECONSTRUCTION