1) Gastric cancer is most common in Japan and China and generally affects the elderly. Risk factors include diet, H. pylori infection, and family history. 2) The majority of gastric cancers are adenocarcinomas. Early gastric cancers are usually cured by resection, while advanced cancers have a poor prognosis. 3) Treatment involves surgical resection with lymph node dissection. The extent of lymphadenectomy depends on the region, with D2 dissection being standard in Asia.

1. Gastric cancer
Hamzeh Halawani M.D.
American University of Beirut

2. EPIDEMIOLOGY
• The most common cancer among men in Japan.
• Highest incidence in China
• Generally-- Disease of the elderly
• Lower socioeconomic status
• Blacks 2 times > whites
Younger patients-- more of the diffuse variety
• Large
• Aggressive,
• Poorly differentiated,
• Sometimes infiltrating the entire stomach (linitis plastic)

3. Primary
Common Primary
• Adenocarcinoma (95%),
• Lymphoma (4%),
• Malignant GIST (1%)
Rare Primary
• Carcinoid, Angiosarcoma, Carcinosarcoma,
and Squamous cell carcinoma

4. Secondary
From :
 Melanoma , Breast(Blood born)
 Colon or Pancreas (Direct ext.)
 Ovary (By peritoneal seeding )

5. ETIOLOGY
More common in
- Pernicious anemia
- Blood group A
-A family history of gastric cancer
- Environmental factors appear more related
to the intestinal form

6. Factors Increasing or Decreasing the
Risk of Gastric Cancer
Increase risk
• Family history
• Diet (high in nitrates, salt, fat)
• Familial polyposis
• Gastric adenomas
• Hereditary nonpolyposis
colorectal cancer
• Helicobacter pylori infection
• Atrophic gastritis, intestinal
metaplasia, dysplasia
• Previous gastrectomy or
gastrojejunostomy (>10 y ago)
• Tobacco use
• Ménétrier's disease
Decrease risk
• Aspirin
• Diet (high fresh fruit and
vegetable intake)
• Vitamin C

7. Premalignant Conditions

8. PATHOLOGY
Dysplasia
- Universal precursor
Mild dysplasia - endoscopic
biopsy/surveillance, and Helicobacter
eradication

9. Early Gastric Cancer
Mucosa and submucosa, regardless of lymph
node status
• 10% have lymph node metastases
 70% well differentiated
 30% poorly differentiated
Cure rate with adequate gastric resection and
lymphadenectomy - 95%

10. Types/SubTypes(Early Gastric Cancer)
• Type I Exophytic lesion extending into the gastric lumen
• Type II Superficial variant
IIA Elevated lesions with a height no more than the
thickness of the adjacent mucosa
IIB Flat lesions
IIC Depressed lesions with an eroded but not deeply
ulcerated appearance
• Type III Excavated lesions that may extend into the
muscularis propria without invasion of this layer by actual
cancer cells

11. Pathologic types of early gastric cancer

12. Japanese classification of early gastric
cancer

13. Advanced gastric cancer
Involves the muscularis
Macroscopically classified by Bormann into
four types
Types III and IV are commonly incurable

14. Gross Morphology and Histologic
Subtypes
Four Gross forms :
• Polypoid
• Fungating
• Ulcerative
• Scirrhous

15. Borrmann classification of advanced
gastric cancer

16. • Polypoid tumors are not ulcerated
• Fungating tumors are elevated intraluminally,
but also ulcerated
• Ulcerative tumors (self-descriptive)
• Scirrhous infiltrate the entire thickness of the
stomach (linitis plastica) poor prognosis, involve
entire stomach

17. Important Prognostic Indicators
• Lymph node involvement
• Depth of tumor invasion
• Tumor grade (degree of differentiation: well,
moderately, poorly)

18. Histologic Classifications

19. Lauren classification
• Intestinal type (53%),
• Diffuse type (33%),
• Unclassified (14%).
The Intestinal type associated with
chronic atrophic gastritis, severe intestinal
metaplasia, and dysplasia, less aggressive than the
diffuse type
The Diffuse type of gastric cancer associated with
younger patients and proximal tumors, poorly
differentiated

20. Ming classification
• Expanding (67%)
• Infiltrative (33%)

21. World Health Organization Histologic
Typing
• Adenocarcinoma
• Papillary adenocarcinoma
• Tubular adenocarcinoma
• Mucinous adenocarcinoma
• ---------------------------------------
• Signet-ring cell carcinoma
• Adenosquamous carcinoma
• Squamous cell carcinoma
• Small cell carcinoma
• ---------------------------------------
• Undifferentiated carcinoma
• Others
The Japanese classification(more detailed)

22. Transperitoneal spread
Indicates Incurability
- Ascites
- Advanced palpated either abdominally or
rectally as a tumour ‘shelf ’
- Ovaries (Krukenberg’s tumours)
- Umbilicus (Sister Joseph’s nodule)
Laparoscopy and cytology

23. Staging
• Japanese classification
–Based on Anatomic involvement
• AJCC American Joint committee on cancer7th
edition
• 15 Lymph node the minimum recommended
–SEER study , number of LN correlates with
OS

24. CLINICAL MANIFESTATIONS
- Weight loss
- Anorexia / early satiety
- Abdominal pain
- Nausea, vomiting, bloating
- Acute GI bleeding (5%)
- Chronic occult blood loss is common ( iron
deficiency anemia and heme-positive stool)
- Dysphagia (cardia)

25. Paraneoplastic syndromes
Rare
Trousseau's syndrome (thrombophlebitis)
Acanthosis nigricans (hyperpigmentation of
the axilla and groin)
Peripheral neuropathy

26. Physical examination
Focused examination :
Neck
Chest
Abdomen
Rectum and pelvis

27. • Cervical
• supraclavicular (on the left referred to as
Virchow's node)
• axillary lymph nodes may be enlarged
FNAC

28. - Metastatic pleural effusion
- Aspiration pneumonitis
- An abdominal mass indicate a large primary
tumor
- Liver metastases
- Carcinomatosis - Krukenberg's tumor
- Palpable umbilical nodule (Sister Joseph's
nodule) malignant ascites

29. Rectal exam
• Heme-positive stool
• Hard nodularity extraluminally and
anteriorly
Drop metastases, or rectal shelf of Blumer in
the pouch of Douglas

30. DIAGNOSTIC EVALUATION
Peptic ulcer / Gastric cancer clinical grounds
impossible
• age 45 years Endoscopy and biopsy
• new onset dyspepsia
• alarm symptoms Double-contrast barium
• family history

31. Preoperative staging
• Abdominal/Pelvic CT scanning ( contrast)
• MRI
• Locally EUS - enlarged (>5 mm) perigastric and
celiac lymph nodes
• EUS- early gastric cancer (T1) from more
advanced tumors
• Positron Emission Tomography Scanning(+CT)
• Staging Laparoscopy and Peritoneal Cytology

32. TREATMENT
• Surgical resection Curative treatment
Exceptions:
• cannot tolerate operation
• overwhelming metastatic disease

33. Goal
• R0 resection / adequate lymphadenectomy
(only 50%)
• Negative margin of at least 5 cm required
(4cm is adequate NCCN)
• In diffuse variety, beyond 5 cm desirable
• Routine splenectomy is not indicated

34. Gastrectomy
Curative - Primary tumor resected en bloc
with adjacent involved organs (distal
pancreas, transverse colon, or spleen)
Palliative - indicated in incurable disease

35. Subtotal gastric resection
- ligation of the left and right gastric and
gastroepiploic arteries at origin
- en bloc removal of the distal 75% of the stomach, 2
cm of duodenum
- the greater and lesser omentum, associated
lymphatic tissue
• Reconstruction - Billroth II gastrojejunostomy
• the spleen and pancreatic tail not removed In
absence of involvement
• operative mortality - 2 to 5%

38. Total gastrectomy
• with Roux-en-Y esophagojejunostomy in
proximal gastric adenocarcinoma
• Total gastrectomy - superior functional, not
oncologic, results for proximal gastric cancer

40. EMR, ESD
• Tis or T1a
• First in Japan
• En-block resection for ESD
• Endoscopic Robotic ?
– https://www.youtube.com/watch?v=0hQKl7HYOI
o
– https://www.youtube.com/watch?v=L9d4PncxRlE

41. Extent of Lymphadenectomy
• The Japanese Research Society for Gastric Cancer
numbered the lymph node stations that potentially drain
the stomach
Generally these are grouped into
• level D1
• level D2
• level D3
• N1- Perigastric LN lesser curvature (1,3,5) greater
curvature (2,4,6)
• N2- Left gastric artery 7, common hepatic artery 8, celiac
artery 9, splenic artery 10,11
• N3 Paraaortic

42. The standard operation for gastric cancer is
D2 Is standard of care in Asia,
D1 is recommended in West