Malignancy of the stomach

1. Malignant neoplasms of
the stomach
DR MASSAM

2. Objectives
By the end of this presentation, students should be able to:
1. Describe the surgical anatomy of the stomach
2. Describe risk factors and histological subtypes of Gastric cancer.
3. Take a focused history and examine a patient suspected to have
gastric cancer.
4. Outline the diagnostic and metastatic investigations of gastric cancer
patient
5. Describe the pre-referral management of a patient with gastric
cancer

3. Anatomy of stomach

6. Introduction
The three most common primary malignant gastric neoplasms are
• Adenocarcinoma (95%),
• Lymphoma (4%),
• Malignant gastrointestinal stromal tumor (GIST) (1%)
Gastric adenocarcinoma is a malignant epithelial tumour,
originating from glandular epithelium of the gastric mucosa.

7. Epidemiology
• Gastric cancer is the 3rd most
common cause of cancer death and
5th most common cancer
worldwide.
• The incidence is highest in Japan,
and Korea
• Male to female ratio 2 : 1
• 2x Blacks then whites
• Older age
• Shift of site – distal to proximal
cardia due to smoking and alcohol
abuse

8. Classification
WHO Classification:
1. Adenocarcinoma
a. Papillary adenocarcinoma
b. Tubular adenocarcinoma
c. Mucinous adenocarcinoma
d. Signet-ring cell carcinoma
2. Adenosquamous carcinoma
3. Squamous cell Ca
4. Small cell Ca
5. Undifferentiated Ca
6. Others

9. Risk factors
Increase risk
Family history
Diet (nitrates, salt, fat)
Familial polyposis
Gastric adenomas
Hereditary nonpolyposis colorectal cancer
Helicobacter pylori infection
Previous gastrectomy or gastrojejunostomy (>10yrs)
Tobacco use
Chronic alcohol consumption
Menetrier’s disease – rare disorder xzed by mucosal folds in the stomach
Blood type A
Decrease risk
Aspirin
Diet (high fresh fruit and vegetable)
Vitamin C

10. Pathogenesis…

11. Clinical features
Generally nonspecific and contribute to its frequently advanced stage at the
time of diagnosis.
• Weight loss and Persistent abdominal pain are the most common
symptoms at initial diagnosis .
• Weight loss usually results from insufficient caloric intake & Postprandial fullness.
• Loss of appetite.
• Abdominal pain tends to be epigastric, vague and mild (early in the
disease) but more severe and constant as the disease progresses.
• Gastric outlet obstruction, non-bilious vomiting, (+)succussion splash.
• Dysphagia, cancers arising in the proximal stomach.

12. Other clinical features…
• Early satiety , form of diffuse-type gastric cancer called linitis
plastica, from poor distensibility of the stomach.
• Occult gastrointestinal bleeding with or without iron deficiency
anemia.
• Overt bleeding, melena or hematemesis.
• Pseudoachalasia syndrome involvement of Auerbach's plexus due to
local extension or to malignant obstruction near the gastroesophageal
junction.

13. Signs of tumor extension
(late feature)
• Virchow’s node : left supraclavicular node
• Irish’s node: Left axillary nodes
• Sister Mary Joseph nodule: Umbilical metastases.
• Peritoneal spread (transcoelomic) can present with an enlarged ovary
Krukenberg's tumor
• A mass in the cul-de-sac (rectouterine or rectovesicle pouch) on rectal
examination or PV exams Blummer's shelf
• Ascites: Peritoneal carcinomatosis.
• Palpable liver mass with or without jaundice due to hepatic metastases.

14. Diffuse seborrheic keratoses

15. Acanthosis nigricans

16. Clinical features…
Succussion splash test:
• A sloshing sound heard through
stethoscope during sudden mvt of
the pt on abdominal examination.
• It is elicited by placing a
stethoscope over the upper
abdomen and rocking the pt back
and forth at the hips.
• Retained gastric material greater
than three hours after meal will
generate a splashing sound
indicating the presence of hollow
viscus filled with fluid and gas.

17. Diagnosing ….
1) Barium contrast radiographs
Single-contrast examinations have a diagnostic accuracy of 80%
double-contrast (air and barium) 90%
 Ulceration,
 The presence of a gastric mass,
 Loss of mucosal detail,
 Distortion of the gastric silhouette

18. Barium contrast radiographs

19. Cont…
2 ) Intraluminal contrast, CT scan reliably demonstrate infiltration
• Gastric wall by tumor,
• Gastric ulceration,
• Hepatic metastasis
• Less reliable with regard to invasion of adjacent organs or the
presence of lymphatic metastases.
• 40% to 50% accuracy rate for ct scanning in preoperative local staging
of gastric carcinoma

21. Endoscopic Ultrasound
• Excellent at delighting sub epithelial lesions , perigastric lymph nodes
involved.
• But because of a limited depth of tissue penetration, however,
endoscopic ultrasound is unable to detect hepatic metastases.
• Operator dependent and tends to overestimate the T stage of the
tumor, and may underestimate lymph node involvement since
normal-sized nodes (<5 mm) can harbor metastases.
• Accurate in distinguishing early gastric cancer from more advanced
tumors.

22. Endoscopy
• 90% of gastric cancers are detected by upper endoscopy and biopsy
• In cases of known gastric cancer, endoscopy is helpful to
 Establish treatment goals (cure or palliation),
 TNM stage,
 Assessment of response to previous therapeutic approaches

23. Other modalities
CXR
PET -scan
Staging Laparoscopy reveal small peritoneal implants or liver
metastases that were not detected on preoperative imaging studies
Peritoneal Cytology

24. Management …
• Surgery is the only curative treatment for gastric cancer
(Gastrectomy)
• Is the best palliation and provides the most accurate staging.
• Exceptions :-
1 patients who cannot tolerate an abdominal operation.
2 patients with overwhelming metastatic disease

25. Goal of curative surgical treatment
• Resection of all tumor.
• All margins (proximal, distal, and radial) should be negative
• Adequate lymphadenectomy performed
• Grossly negative margin of at least 5 cm, since some gastric tumors
are quite infiltrative and tumor cells can extend well beyond the
tumor mass

27. INTRAOPERATIVE COMPLICATIONS
Hemorrhage
Acute ischemia of the left lobe of liver
Injury to Spleen Pacreas , common bile duct
Disruption of Ampulla of Vater

28. POST OPERATIVE COMPLICATIONS
• IMMEDIATE ( WITHIN 30 DAYS OF SURGERY )
• EARLY (W ITHIN 6 MONTHS )
• LATE ( AFTER 6 MONTHS )

29. IMMEDIATE COMPLICATION
ATELECTASIS 12 – 20 %
PNEUMONIA 9%
RESPIRTORY FAILURE 3 %
PULOMNARY EMBOLISM 0.05%
VENOUS THROMBOSIS OF LOWER LIMBS
WOUND INFECTION
SUBPHRENIC ABSCESS
ACUTE PANCREATITIS

30. EARLY COMPLICATIONS
POST OPERATIVE ANASTOMOTIC HEMORRHAGE
ANASTOMOTIC LEAK
DUODENAL STUMP LEAK
SMALL BOEL OBSTRUTION
STOMAL OBSTRUCTION

31. Management at health center or dispensary
Perform conservative management such as :-
• Insert IV lines for giving IV fluids ( RL, NS or DNS depending on RBG )
• Draw blood sample for Hb, BG and X-Match
• Give anti pain whenever necessary
• Catheterize the patient to monitor urine output
• Perform any available imaging
• Refer to the higher hospital for further management including
possible gastrectomy.

32. Refferences
• Schwartz principles of surgery 10th edition
• Subiston textbook of surgery 20th edition
• Bailey and love short practice of surgery 27th edition
• Greenfield surgery 5th edition
• Manipal manual of surgery 4th edition