There are marked variations in the incidence of gastric cancer worldwide. The UK it is approximately 15 per 100000 per year The USA 10 per 100000 per year Eastern Europe 40 per 100 000 per year. It is more common in Japan—70 per 1,00,000 population. Common in males 2:1. Decrease incidence in western world (Western Europe and US)—last four decades.

1. GASTRIC CANCER
DR .WAQAS ARSHAD BAJWA
PGR SURGERY

2. Objectives
• Anatomy
• Incidence
• Anatomical Sites
• Aetiology
• Pathology
• Clinical presentation
• Differentional diagnosis
• Metastasis
• Staging
• Treatment

8. Incidence
• There are marked variations in the incidence of gastric cancer
worldwide.
• The UK it is approximately 15 per 100000 per year
• The USA 10 per 100000 per year
• Eastern Europe 40 per 100 000 per year.
• It is more common in Japan—70 per 1,00,000 population.
• Common in males 2:1.
• Decrease incidence in western world (Western Europe and US)—last
four decades

9. Common Site of Occurrence

10. Aetiology
• Familial—10%.
• Gastric mucosa of people with blood group ‘A’ is more susceptible for
carcinogens—diffuse type
• Gastric polyps, adenomatous polyp >2 cm.
• Pernicious anaemia—high-risk 6 times.
• Gastric remnant—15 years after gastrectomy and GJ.
• Diet—high salt diet, food with more nitrosamines
• Chronic gastritis (atrophic, autoimmune)

11. • Smoking
• Alcohol.
• Helicobacter pylori infection—high-risk 6-fold increase in incidence.
intestinal type of gastric cancer.

12. Precursor Lesions of Carcinoma Stomach
• Chronic atrophic gastritis
• Adenomatous gastric polyps
• Intestinal metaplasia
• Menetrier’s disease
• Benign gastric ulcer
• Stomach remnant (stump carcinoma)

13. Pathology
• Gastric cancer
• Early gastric cancer
• Advanced gastric cancer.
• Early gastric cancer is defined as cancer limited to the mucosa and
submucosa with or without lymph node involvement (T1, any N).

14. Pathology
• . Gross types:
Cauliflower type
Ulcerative type
Leather-bottle (Linitis plastica)
Lauren’s classification : (Histological)
Intestinal type (53%)
Diffuse type (33%)
Unclassified (14%).

16. Depending on the depth of invasion
• Japanese’s classification
1. Protruded.
2. Superficial—elevated (a), flat (b), depressed (c).
3. Excavated.

18. Borrmann’s classification
I. Single, polypoid carcinoma.
II. Ulcerated carcinoma with clear cut margin.
III. Ulcerated carcinoma without clear cut margin.
IV. Diffuse carcinoma—linitis plastica.
V. Unclassified.

20. Molecular pathology of gastric cancer

21. Clinical Features
• Recent onset of loss of appetite and weight, early satiety, fatigue.
• Microcytic, hypochromic anaemia (iron deficiency) is common (40%)
• Upper abdominal pain.
• Vomiting with features of gastric outlet obstruction
• Mass abdomen: Mass in pylorus lies above the umbilicus, nodular,
hard, with impaired resonance, mobile, moves with respiration, all
border well made out
• Secondaries in umbilicus, as Sister Joseph’s nodules (spread through
ligamentum teres).

22. • jaundice, liver may be palpable with secondaries which are hard, nodular (50%)
with umbilication.
• Ascites.
• +ve Troisier’s sign.
• +ve rectovesical secondaries. (Blumer shelf) on per rectal examination
• Anaemia
• Cachexia.
• Haematemesis (15%)
• Melaena.
• Carcinoma stomach can present as perforation to begin with (4%).
• Rarely as secondaries in the liver with silent primary in stomach

24. Blumer shelf

25. Differential diagnosis
• Acid peptic disease; pyloric stenosis with gastric outlet obstruction
• Gastritis
• Pancreatic mass—carcinoma
• Transverse colon mass—carcinoma
• Advanced fixed stomach mass may mimic retroperitoneal or nodal
mass

26. Lymphatic drainage of the stomach

27. Zones of lymphatic drainage in stomach
• Zone 1-inferior gastric: It lies in gastrocolic omentum along the right
gastroepiploic vessels, draining pyloric portion of the greater curve to
pyloric, coeliac and aortic lymph nodes.
• Zone 2-splenic: It lies in gastrocolic and gastrosplenic omentum along
the left gastroepiploic vessels draining from upper half of greater
curve to pancreaticosplenic and aortic lymph nodes.
• Zone 3-superior gastric: There is drainage from proximal two thirds
of the stomach and the upper lesser curve along the left gastric artery.

28. • Zone 4-hepatic: It is from distal portion of lesser curve and pylorus
along hepatic artery into para-aortic nodes
• Lymph node group
• Group I: Perigastric nodes
• Group II: Along the root of major vessels
• Group III: At the root of superior mesenteric artery and
hepatoduodenal
• ligament
• Group IV: Distant lymph nodes.

29. • D1—involvement of group I lymph nodes.
• D2—involvement of group I and II lymph nodes.
• D3—involvement of group I, II and III lymph nodes.
• D4—involvement of group I, II, III and para-aortic nodes

30. Spread of carcinoma of the stomach
• Direct spread:
• Horizontal submucosal spread along stomach wall.
• Vertical spread by invasion across to adjacent structures like—
pancreas, colon, mesocolon, liver.
• Lymphatic spread :
Spread occurs by permeation and embolisation through lymphatics to
subpyloric, gastric, pancreaticoduodenal, splenic, coeliac, aortic, and
later to left supraclavicular lymph nodes (Virchow’s lymph node—
Troisier’s sign)

31. • Blood spread : It occurs to liver (most common) causing multiple liver
secondaries presenting as multiple, hard, nodules with umbilications
due to central necrosis.
Later lungs and bones can get involved

32. Transperitoneal spread
• Krukenberg’s tumour
• Rectal secondaries (Blumer shelf)
• Sister Mary Joseph umbilical secondaries are through transperitoneal
spread.
• Transperitoneal spread is best identified through laparoscopy and
confirmed

33. Investigations
• Hb%, haematocrit.
• Barium meal (Irregular filling defect).
• Single contrast barium studies—sensitivity is 75%.
• Double contrast barium studies—sensitivity is 90–95% in the
detection of gastric cancer, comparable to endoscopy
• Gastroscopy with biopsy—10 targeted biopsies.
• FNAC from left supraclavicular lymph node when it is significantly
palpable

34. • Endosonography:
EUS is useful to detect the involvement of layers of the stomach
Nodal status and to define whether tumour is early or advanced.
All 5 layers are visualised as alternate hypo- and hyperechogenic
areas.
It gives 90% accuracy for T staging and 80% of nodal staging.
• CT scan abdomen and CT thorax in proximal tumours to see size,
extent, infiltration, LN status, secondaries and operability

35. • CA 72-4 is important tumour marker to evaluate the relapse.
• CEA, CA 19-9, CA 12-5 are other markers

37. Barium meal findings in carcinoma stomach
• Irregular filling defect ™
• Loss of rugosity
• ™
Delayed emptying ™
• Dilatation of stomach in carcinoma pylorus ™
• Decreased stomach capacity in linitis plastica ™
• Margin of the lesion projects outward from the ulcer/lesion into the gastric lumen—
Carmanns meniscus sign

38. TNM Staging of Carcinoma Stomach
• Tumour – T
Tx—tumour cannot be assessed
T0—no evidence of tumour
Tis—carcinoma in situ, intraepithelial tumour without invasion
T1a—invades lamina propria or muscularis mucosa
T1b—invades submucosa
T2—invades muscularis propria
T3—invades subserosal connective tissue without invasion of visceral
peritoneum or adjacent structures
T4a—invades serosa/visceral peritoneum
T4b—invades adjacent structures

39. • Nodes – N
Nx—cannot be assessed
N0—no nodal spread
N1—1–2 regional nodes
N2—3–6 regional nodes
N3a—7–15 regional nodes
N3b—16 or more nodes
Metastases – M
M0—no distant spread
M1—distant spread present

40. Treatment
Preoperative preparation
• Correction of anaemia, nutrition, fluid and electrolyte
• Cardiac, respiratory and renal status assessment
• Stomach wash using normal saline
• Prophylactic antibiotic as achlorhydria in gastric lumen allows
colonisation of Streptococcus faecalis, E. coli, bacteroides,
Staphylococcus ablus
• Blood/FFP may be needed preoperatively and for surgery

41. • In early carcinoma proper lymph nodal clearance is important
• Maintain a 5-cm margin proximally and distally to the primary lesion.
• Early growth in pylorus: ™
Lower radical gastrectomy with removal of
tumour, proximal 5 cm clearance, nodal clearance, greater and lesser
omentum, distal pancreas and spleen
• Billroth II anastomosis or Roux-en-Y anastomosis is done
• Postoperatively adjuvant chemotherapy should be given
• D1 or D2 nodal dissection should be done for adequate clearance in
curative surgery

42. • Growth in body, proximal growth, diffuse carcinoma and generalised
linitis plastica are the indications for total radical gastrectomy with
oesophagojejunal anastomosis.
• Neoadjuvant chemotherapy in advanced gastric cancer prior to
surgery and later gastrectomy
• Palliative procedures like palliative partial gastrectomy, anterior
gastrojejunostomy, Devine’s exclusion procedure, luminal stenting in
proximal inoperable growths, chemotherapy are used in inoperable
cases

43. • Surgery is the treatment of choice for carcinoma stomach.
• Proximal-third
Extended gastrectomy, including the distal esophagus
Middle-third
Total gastrectomy and D2 LN dissection
Distal-third
Intestinal-type: Subtotal gastrectomy with D2 LN dissection
Diffuse-type: Total gastrectomy with D2 LN dissection

44. Signs of inoperability
• Adherent to pancreas or colon or mesocolon
• Ascites
• Para-aortic lymph nodes
• Secondaries in liver
• Palpable mass is incurable but can be resectable surgically
• Blumer shelf
• Left supraclavicular nodes
• Sister Mary Joseph nodule
• ™
Irish node (Left axillary lymph node secondaries

45. Gastrectomies for carcinoma stomach

46. Gasrectomy Billroth I or Bilroth II type

51. Complications
• BILROTH 1
• Stomal oedema
• Gastric paresis
• Stomal obstruction,
• Anastomotic dehiscence and
• Bile leak,
• Sepsis
• Subphrenic abscess formation

52. • BILROTH 2
• Gastroparesis.
• Dumping syndrome.
• Roux stasis syndrome.
• Afferent loop syndrome

53. Prognosis
• In early gastric cancer which has undergone good surgical resection, 5-year
survival rate is 70–90% in Japan.
• In India, 5-year survival rate is 20%.
• In advanced gastric cancer it reduces to 20–25% in Japan. In other
countries it is still worser.
• Overall prognosis is worse in carcinoma stomach.
• When serosa is not involved 5-year survival is 50%
• . When serosa is involved it is 20%.
• Nodal spread is a bad prognostic factor.
• Involvement of more than 4 nodes carry poor prognosis.

54. Recurrence
• Overall 5-year survival rates after the diagnosis of gastric cancer are
10–21%.
• Patients who undergo a potentially curative resection have a 5-year
survival rate of 24–57%.
• Recurrence rates after gastrectomy remain high, ranging from 40–
80%.
• Most recurrences occur within the first 3 years
• Loco-regional failure rate is highest at the anastomosis or stump
(25%) > stomach bed (21%) > regional nodes.

55. Surveillance
• Follow-up should include a complete history and physical
examination every 4 months for 1 year, then every 6 months for 2
years, and then annually thereafter
• Yearly endoscopy should be considered in patients who have
undergone a subtotal gastrectomy

56. According to Borrman’s classification, Linnitis plastica is:
a. Type I
b. Type II
c. Type III
d. Type IV

57. Peritoneal dissemination of gastric cancer is best detected by:
• a. USG
• b. Laparoscopy
• c.CT
d. MRI

58. Locally invasive gastric carcinoma. Investigation of choice to know
depth of cancer invasion:
• a. CECT
• b. MRI
• c. Barium
• d. EUS

59. An ulcero-proliferative lesion in the antrum of the stomach 6cm in
diameter, invading the serosa, with 10 enlarged lymph nodes around
and pylorus with no distant metastasis, the TNM staging is:
• a. T2N1M0
• b. T3N2M0
• c. T4N1M0
• d. T1N3M0

60. An adult presented with hematemesis and upper abdominal pain.
Endoscopy revealed a growth at the pyloric antrum of the stomach. CT
scan showed growth involving the pyloric antrum without infiltration or
invasion into surrounding structures and no evidence of distant
metastasis. At laparotomy neoplastic growth was observed to involve
the posterior wall of stomach and the pancreas extending 6 cm up to
tail of pancreas. What will be the most appropriate surgical
management
a. Closure of the abdomen
b. Antrectomy and vagotomy
c. Partial gastrectomy + distal pancreatectomy
d. Partial gastrectomy + distal pancreatectomy + splenectomy

61. Kally, a 60 years old male diagnosed to have carcinoma stomach. CT
scan of abdomen showed a mass measuring 4 × 4 cm in the antrum
with involvement of celiac nodes and right gastric nodes. Management
of choice is
• A. Total gastrectomy
• b. Subtotal gastrectomy
• c. Palliative
• d. Chemotherapy

62. Operability in carcinoma stomach is indicated by all except:
• a. Involvement of omental nodes
• b. Involvement of lymph nodes at the celiac axis
• c. Lymph node at porta hepatis
• d. Solitary metastatic nodule in the liver e. Krukenberg tumo