This document summarizes information about gastric cancer. It discusses the following key points: - Gastric cancer rates are highest in East Asia and parts of Latin America and lowest in North America and parts of Western Europe. - Risk factors include H. pylori infection, pernicious anemia, and family history. Protective factors include aspirin, fruits and vegetables, and vitamin C. - Early symptoms are nonspecific but later can include dysphagia or outlet obstruction. Diagnosis involves endoscopy, biopsy, and imaging. - Treatment involves surgery, which may be preceded by neoadjuvant chemotherapy and radiation. Outcomes have improved with more extensive lymph node dissection.

1. Gastric Cancer
AYMEN KAREEM ALMAJMAIE
Faculty of medicine
Fourth year (BA)

2. Epidemiology

4. Geographic Distribution
Highest rates (over 40 per 100,000 in
males) are reported from Japan, China, the
former USSR, and certain countries in Latin
America.
The lowest rates (< 15 per 100,000) are
seen in North America (specifically, its white
population), India, the Philippines, most
African countries, some countries in Western
Europe, and Australia.

7. Of 136 persons eligible to participate in the study, 135
(99%) consented to take part.
Median age was 39 (range 19 – 79); 82 participants
(61%) were women.
Twenty-seven (20%) reported having some knowledge
of H. pylori, but none had been tested or treated for the
infection.
Ninety-seven (72%) participants had active H. pylori
infection

8. Gastric cancer is more common in
patients with pernicious anemia, blood
group A, or a family history of gastric
cancer.
Environmental factors appear to be
more related etiologically to the intestinal
form than the diffuse form.

9. Factors increasing the risk of gastric
cancer:

10. Factors decreasing the risk of gastric cancer:
Aspirin
Diet (high fresh fruit and vegetable intake)
Vitamin C

11. Helicobacter Pylori:
› Chronic helicobacter pylori infection
increases the risk of gastric cancer about
threefold when compared to uninfected
patients

12. Premalignant
conditions of the
stomach

13. ›1. Polyps
›2. Atrophic gastritis
›3. Intestinal metaplasia
›4. Gastric remnant cancer
›5. Ménétrier's disease

15. Clinical Presentation

16. Proximal tumors may present with dysphagia. Antral tumors may present with outlet obstruction.

17. Diagnosis
Double
contrast
barium
Endoscopy
Endoscopic
Ultrasound
(EUS)
diagnostic accuracy approaches 98%. 90% accuracy
No ability to distinguish between malignant and benign ulcers.

18. And tables to compare data
A B C
Yellow 10 20 7
Blue 30 15 10
Orange 5 24 16

19. Gross Pathology

20. Treatment

21. ›What is
›adjuvant
›and
›neoadjuvant therapy

23. Neoadjuvant Therapy
Radiation alone
1970’s in Russia 152 patients were randomly
assigned to surgery alone or preop radiation with 20
Gy a week prior to surgery. Five year survival rates
were 30% and 39% respectively.
In 1998 a Chinese group reported a prospective
series of 370 patients who underwent surgery only or
had 40 Gy preop radiation. Five year survival was
19.8% vs 30.1% with radiation. Resectability and
radical resection rates were also improved.

24. Radiation alone
In both studies reported perioperative mortality
and anastamotic leak rates were not
significantly different.
Further studies in radiation alone were largely
abandoned in favor of studies including
chemotherapy.

26. Chemotherapy alone
A randomized Netherlands study (DGCT) was unable
to show any difference with preop chemotherapy.
This may be in part due to the regimen used – FAMTX
(FU, doxyrubicin, methotrexate).
In the U.K. the MAGIC trial using ECF (epirubicin,
cisplatin, FU) has shown promising preliminary
results, with 10% more resectable cases and improved
disease-free survival.

27. Combined chemoradiation therapy
Has shown a beneficial impact on surgical outcomes in
esophageal and rectal cancers, making it an attractive
approach for gastric cancer as well.
The M.D.
Anderson Cancer Center reported several studies, one in
2004 where patients who underwent preop
chemoradiotherapy – FU, leucovorin, cisplatin, and 45 Gy in
25 fractions over 5 weeks – achieved pathological complete
and partial response in 64% of all operated patients.

28. Chemoradiation therapy
These patients showed a significantly longer
median survival of 64 months in comparison to
13 months in patients who did not reach
complete or partial response.
Further clinical trials are warranted to further
show any benefit of neoadjuvant
chemoradiation.

29. Surgical Treatment
Aggressive resection of gastric cancer is justified
in the absence of distant metastatic spread.
The surgery is tailored mainly to the location of
the tumor and known pattern of spread.
R0 resection should be achieved, with a minimum
of 6cm margins from gross tumor.
R0 – tumor free margins
R1 – microscopic disease
R2 – gross tumor at margins
Minimum of 15 nodes should be removed.

30. Tumors in the cardia and proximal stomach
account for 35-50% of gastric
adenocarcinomas.
For these tumors a total gastrectomy should be
performed, as opposed to proximal gastric
resection which is associated with higher
morbidity and mortality rates.
Distal tumors may be removed by distal
gastrectomy as long as adequate margins are
achieved.

31. The extent of lymphadenectomy remains
controversial.
The JGCA classifies the lymph node basins into 16
basins,
and are grouped according to the location of the
primary tumor as either D1, D2, or D3 nodes. In
general:
D1 – removal of group 1 nodes along the lesser and greater
curvature.
D2 – D1 plus group 2 nodes along the left gastric, common
hepatic, celiac, and splenic arteries.
D3 – D2 plus para-aortic and distal lymph nodes

32. Lymph Node Stations

34. A 1993 survey by the ACS showed a 77.1% resection
rate in 18,365 patients, with a postoperative mortality
rate of 7.2% and 5-year survival rate of 19%. Of
these only 4.7% were D2 dissections.
In comparison,
the Japanese routinely perform D2 dissections, with
5-year survival rates above 50%. Although earlier
detection accounts for much of the survival benefit,
when comparing cancers in the same stage, the
Japanese continue to have improved surviva

35. Based on these findings, many groups
are recommending “over-D1”
lymphadenectomy for gastric cancers in
Western society.
The large difference between the
Japanese results and Western results
remains largely an enigma.

36. In 2001 the Southwest Oncology Group
trial was published, showing for the first
time in a large prospective randomized
trial a survival benefit for patients
undergoing gastrectomy for cancer.
Median survival was 27 months in the
surgery only group, and 36 months after
chemoradiotherapy.

37. Outcomes
Recurrence rates remain high, from 40 to 80%
depending on the series being quoted.
Locoregional failure rate 38 to 45%, with most
recurrence in the gastric remnant at the
anastamosis, gastric bed, and lymph nodes.
Surveillance is important.
Patients should be followed every 4 months for
the first year, then 6 months for 2 more years.
Yearly endoscopy should be performed for
subtotal gastrectomies.

38. Complicaion

39. Prevetion

40. • In Korea, screening was initiated in 1999 and
involves upper endoscopy or upper gastrointestinal
series (UGI) for patients 40 years or older every 2
years.
• As a result of this screening program, more than
50% of gastric cancers in Korea are diagnosed at an
early stage, compared to fewer than 10% in Western
countries.

41. He changed his life , when you Do ?
#cancer_survivor