Gastric carcinoma in detail-its types, risk factors, etiology, clinical manifestations, pathophysiology, classification and management

1. GASTRIC
CARCINOMA

2. Seminar on Gastric
Cancer
Presenter
Ms Alisha Talwar
M.Sc Nursing II year

3. Content
• Anatomy and Physiology of Stomach
• Definition
• Incidence and epidemiology
• Risk factors and causes
• Pathophysiology
• Clinical Manifestations
• Diagnosis
• Management-Medical, Surgical and Nursing

4. Carcinoma
• The most common type of cancer in humans is carcinoma.
Carcinoma is a cancer that begins in tissue that lines the inner or
outer surfaces of the body.
Neoplasm
• a new and abnormal growth of tissue in a part of the body,
especially as a characteristic of cancer.
• "carcinoma of the cervix is a common neoplasm in women"

5. Anatomy of Stomach
• J-shaped organ
• Has two surfaces (the anterior &
• posterior)
• Has two curvatures (the greater
• & lesser)
• Has two orifices (the cardia & pylorus).
• Parts are- fundus, body and pyloric antrum.

8. Blood Supply
• The left gastric artery
• Right gastric artery
• Right gastro-epiploic artery
• Left gastro-epiploic artery
• Short gastric arteries
The corresponding veins drain
into portal system. The lymphatic
drainage of the stomach
corresponding its blood supply.

9. Physiology
• Digestion of food, reduce the size of food
• Acts as reservoir
• Absorption of Vitamin B12 ,Iron and Calcium

10. Gastric Cancer
• An abnormal growth of cells of stomach which tend to proliferate in
an uncontrolled way and, in some cases, to metastasize.

11. Gastric Cancer (Types)
Epithelial 1. Primary
Adenocarcinoma
Gastrointestinal stromal tumors
‘GIST’
Lymphoma
2. Secondary: invasion from adjacent
tumors.
Benign Malignant

12. Geographical Distribution of Gastric Cancer

13. Incidence
• 760,000 cases of stomach cancer are diagnosed worldwide (NCI,
2008)
• 723,000 cancer-related deaths are caused by stomach cancer each
year worldwide (WHO)
• Fifth most common cancer worldwide
• Third leading cause of cancer-related deaths.
• The incidence of gastric cancer in India is low compared to
developed countries (Sharma A., & Radhekrishna V. 2011).
• Southern part and north-eastern states of India, where the incidence
is comparable to high-incidence areas of world.

14. Contd….
• Most (85%) cases of gastric cancer are adenocarcinomas that occur
in the lining of the stomach (mucosa).
• Approximately 40% of cases develop in the lower part of the
stomach (pylorus)
• 40% develop in the middle part (body)
• 15% develop in the upper part (cardia).

15. American institute of cancer research

17. Gastric Carcinoma
55 year old Japanese male who is living in Japan &
working in industry.
DEFINITION Malignant lesion of the stomach.Epidemiology & Risk Factors
Can occur at any age
But Peak incidece
Is 50-70 years old.
It is more aggressive
In younger ages.
Japan has the world
highest Rate of
gastric cancer.
Studies have confirmed
that incidence decline in
Japanese immigrant to
America.
dust ingestion
from a variety
of industrial
processes
may be a risk.
Twice more common
In male than in female
Incidence of Gastric Carcinoma:
Japan 70 in100,000/year
Europe 40 in 100,000/year
UK 15 in 100,000/year
USA 10 in 100,000/year
It is decreasing worldwide.

18. Gastric Carcinoma:
Risk Factors
Predisposing :
1. Pernicious anemia
& atrophic gastritis
(achlorhydra)
2. Previous gastric
resection
3. Chronic peptic ulcer
(give rise to 1%)
4. Smoking.
5. Alcohol.
Environmental:
1.H.pylori infection
Sero(+)patients
have 6-9 folds risk
2.low
socioeconomic
Status
3. Nationality
(JAPAN)
4. Diet (prevention)
Genetic:
1.Blood group A
2.HNPCC:
Heriditory non-
polyposis colon
cancer.

19. Contd…
• Evidence suggest that gastric cancer may be linked to diet, such as
salty food, smoked fish, preserved meats, and low in fresh fruits and
vegetables.
• Some studies have found that a diet high in red meat is another
possible risk factor. Eating red meat an average of about twice a day
seems to raise the risk of stomach cancer. This risk is increased even
more if the meat is barbecued and well done.
• Some studies also suggests that workers in the coal, metal, and
rubber industries are also at risk

20. Clinical Presentation
Most patients present with advanced stage..
why?
They are often asymptomatic in early stages.
Common clinical Presentation:
The patient complained of loss of appetite that was followed
by weight loss of 10Kg in 4 weeks.
Patient complains about
epigastric discomfort & postprandial fullness.
He presented to the ER complaining of vomiting of large
quantities of undigested food & epigastric distension.
Dyspepsia
epigastric pain
Bloating
early satiety
nausea & vomiting*
dysphagia*
anorexia
weight loss
upper GI bleeding
(hematemesis, melena,
iron deficiency anemia)

21. Signs
-Anemia.
-Wt.loss (cachexia)
-Epigastric mass,Hepatomegaly,Ascitis
-Jaundice.
-Blumers shelf
-Virchows node
-Sister mary joseph node
-Krukenberg tumor
-Irish node

23. Spectrum of Gastric Cancer
• Proposed progression:
• chronic gastritis
• chronic atrophic gastritis
• intestinal metaplasia
• dysplasia
• adenocarcinoma

26. T1 lamina propria & submucosa
T2 muscularis & subserosa
T3 serosa
T4 Adjacent organs
N0 no lymph node
N1 Epigastric node
N2 main arterial trunk
M0 No distal metastasis
M1 distal metastasis
Staging of gastric cancerSpread of Gastric Cancer
Direct Spread
Blood-borne
metastasis
Lymphatic spread
Transperitoneal
spread
Tumor penetrates the
muscularis, serosa &
Adjacent organs
(Pancreas,colon &liver)
What is important here is
Virchow’s node
(Trosier’s sign)
Usually with extensive
Disease where liver 1st
Involved then lung &
Bone
This is common
Anywhere in peritoneal cavity
(Ascitis)
Krukenberg tumor (ovaries)
Sister Joseph nodule
(umbilicus)

27. Staging of Gastric Cancer
• Two systems:
• Japanese classification (more elaborate and anatomic based)
• Western: developed by American Joint Committee on Cancer
(AJCC) and International Union Against Cancer (UICC) -- more
widely used
• Tumors at GE junction of in cardia of stomach within 5cm of GE
junction
• Classified using esophageal staging

28. Gastric Carcinoma Classification
• Depth of invasion
• EARLY GASTRIC CA - mucosa & submucosa
• ADVANCED GASTRIC CA - into or through muscularis propria
• Macroscopic growth pattern – Ming classification
• Expanding
• Infiltrative - "linitis plastica“
• Histologic subtype
• Intestinal
• Diffuse (gastric); poorly differentiated; "signet ring"

29. 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

30. Ming Classification
1. Expanding type (67%)
2. Infiltrative type (33%)

31. Lauren Classification
1. Intestinal type (53%) It arises in areas of intestinal metaplasia to
form polypoid tumors or ulcers.
2. Diffuse type (33%) It infiltrates deeply in the stomach without
forming obvious mass lesions but spreads widely in the gastric wall
“Linitis Plastica” & it has much more worse prognosis
3. Unclassified (14%)

32. Morphology
• Polypoid
• Ulcerative
• Superficial spreading
• Linitis plastica

34. TNM Classification

35. Differential Diagnosis
1. Gastric ulcer
2. Other gastric neoplasms
3. Gastritis
4. Gastric Polyp
5. Crohns disease.
From history,
Cancer is not relieved by antacids
Not periodic
Not releived by eating or vomiting.

36. Assessment & Diagnosis
• History and Physical Examination
• Complete blood count to rule out anemia
• LFT,RFT
• Amylase & lipase.
• Serum tumor markers (CA 72-4,CEA,CA19-9) not specific may be
elevated but have low sensitivity/specificity
• Stool examination for occult blood
• CXR ,Bone scan.

37. Specific diagnostic tests
• UGI endoscopy with biopsy
• EUS
• Contrast study-Barium Studies
• CT, MRI & US
• Laparoscopry

38. EGD (esophagogastroduodenoscopy)
Diagnostic accuracy is 98%
if upto 7 biopsies is taken.
Double Contrast barium upper GI x-ray
Diagnostic accuracy 90%
WHY?
Diagnostic study of Choice
1.Early superficial gastric mucosal lesion
can be missed.
2. can’t differentiate b/w benign ulcer &
Ulcerating adenocarcinoma.

39. X-ray showing Gastric ulcer
With symmetrical radiating
Mucosal folds.
By histology, no evidence of
Malignancies was observed.
X-ray showing Extensive
carcinoma involving
the cardia & Fundus
Pyloric stenosis

40. CT,MRI & US:
Laparoscopy:
Help in assessment of wall thickness,
metastases (peritoneum ,liver & LNs)
Detection of peritoneal
metastases

42. THE GOLD STANDARD
 It allows taking biopsies
 Safe (in experienced hands)
UGI ENDOSCOPY

44. UGI ENDOSCOPY,contd.
 You may see an ulcer (25%), polypoid mass (25%),
superficial spreading (10%),or infiltrative (linnitis plastica)-
difficult to be detected-
 Accuracy 50-95% it depends on gross appearance, size,
location & no. of biopsies

45. Endoscopic Ultrasonography
• A small, high frequency ultrasound transducer incorporated into the
distal end of the endoscope.
• Advantages:
- superior resolution.
- image not compromised by intervening gases.
- lesion as small as 2-3 mm in diameter can be imaged.

48. Characteristic of BENIGN OR MALIGNANT
MALIGNANTBENIGN
Irregular outline with
necrotic or hemorrhagic
base
Round to oval punched
out lesion with straight
walls & flat smooth base
Irregular & raised marginsSmooth margins with
normal surrounding
mucosa
AnywhereMostly on lesser curvature
Any sizeMajority<2cm
Prominent & edematous
rugal folds that usually do
not extend to the margins
Normal adjoining rugal
folds that extend to the
margins of the base

50. PROGNOSTIC FEATURES
2 important factors influencing survival in resectable gastric cancer:
 depth of cancer invasion
 presence or absence of regional LN involvement
5yrs survival rate:
10% in USA
50% in Japan

51. Management
• Surgery
• Chemotherapy
• Radiotherapy

52. Treatment
Initial treatment:
1.Improve nutrition
if needed by
parentral or enteral
feeding.
2.Correct fluid
&electrolyte
& anemia if they are
present.
Preoperative Care
Preoperative Staging is
important to know its
extent for radical
excision

53. PRE-OPERATIVE CARE
Careful preoperative monitoring
Assess for any nutritional deficiencies & provides nutritional
support
Symptomatic control
Blood transfusion in symptomatic anemia
Hydration
Prophylactic antibiotics as prescribed
ABO & cross-match
Cessation of smoking

54. Basic surgical principles
3 TYPES: TOTAL,SUBTOTAL,PALLIATIVE
ANTRAL DISEASESUBTOTAL GASTRECTOMY
MIDBODY & PROXIMAL TOTAL GASTRECTOMY

55. Total (radical) gastrectomy
Removal of the stomach +distal part of esophagus+
proximal part of duodenum + greater & lesser omenta + LNs
Oesophagojejunostomy with roux-en-y .

56. Subtotal gastrectomy
Similar to total one except that the PROXIMAL
PART of the stomach is preserved
Followed by reconstruction & creating
anastomosis
( by gastrojejunostomy,billroth II )

57. Total gastrectomy
• https://www.youtube.com/watch?v=5rj7M4kZKp0
• https://www.youtube.com/watch?v=TND3SVodajs
Subtotal gastrectomy

58. Palliative surgery
For pts with advanced disease & suffering significant symptoms e.g.
obstruction, bleeding.
Palliative gastrectomy not necessarily to be radical, remove
resectable masses & reconstruct
(anastomosis/intubation/stenting/recanalisation)

59. Other Modalities
Endoscopic resection
Endoscopic tumor ablation
Stent Placement

60. Complications of Surgery
• Bleeding
• Nausea
• Heartburn
• Abdominal pain
• Diarrhoea
• Nutritional Deficiency

61. Chemotherapy
• Cisplatin + epirubicin & infusional 5-FU or + irinotecan
(3Wks) 6 cycles, respond rate is 40%
Complete remissions are uncommon.
Partial responses in 30-50% of cases are transient.
Overall influence on survival has been unclear.
• Adjuvant chemotherapy alone following complete resection has only
minimally improved survival.
• Perioperative treatment and postoperative chemotherapy + radiation
therapy reduce the recurrence rate and prolongs survival.

62. Side-Effects of Chemotherapy
• Nausea and vomiting
• Loss of appetite
• Hair loss
• Diarrhea
• Mouth sores
• Increased chance of infection (Leucopenia)
• Bleeding or bruising after minor cuts or injuries (thrombocytopenia)
• Fatigue and shortness of breath (erythropenia)

63. Immunotherapy
• Immunotherapy is the use of medicines that help a person’s own
immune system find and destroy cancer cells. It can be used to treat
some people with stomach cancer.
• Pembrolizumab (Keytruda) boosts the immune response against
cancer cells. This can shrink some tumors or slow their growth.
• Pembrolizumab is given as an intravenous (IV) infusion, typically every 3
weeks.
• Side-effects are Feeling tired or weak, Fever, Cough, Nausea, Itching,
Skin rash, Loss of appetite, Muscle or joint pain, Shortness of breath,
Constipation or diarrhea and auto immune disorders

64. Radiation Therapy
• Radiation therapy uses high-energy rays or particles to kill cancer
cells in a specific body area.
• Can be used in different ways- Before and after surgery
• External beam radiation therapy is often used to treat stomach
cancer
• Side effects are Skin problems, ranging from redness to blistering
and peeling, in the area the radiation passed through, Nausea and
vomiting, Diarrhea, Fatigue, Low blood cell counts

65. Supportive Treatment
• Nutrition (jejunal enteral feedings or total parenteral nutrition),
• Correction of metabolic abnormalities that arise from vomiting or
diarrhea
• Treatment of infection from aspiration or spontaneous bacterial
peritonitis.
• To maintain lumen patency, endoscopic laser treatment or stenting
for palliation.

66. Nursing Management

67. Assessment
• Symptoms as gastric ulcer.
• Gastric fullness (early satiety), dyspepsia lasting more than 4 weeks,
progressive loss of appetite are initial symptoms.
• Stool samples are positive for occult blood.
• Vomiting may occur and may have coffee-ground appearance.
• Later manifestations include pain in black or epigastric area (often
induced by eating, relieved by antacids or vomiting); weight loss;
hemorrhage; gastric obstruction.

68. Diagnosis
• Imbalanced nutrition: Less than body requirements, related to
anorexia and difficulty eating
• Acute pain, related to surgical incision and manipulation of
abdominal organs
• Risk for ineffective airway clearance, related to upper abdominal
surgery
• Anticipatory grieving, related to recent diagnosis of cancer

69. Interventions
• Monitor nutritional intake and weigh patient regularly.
• Monitor CBC and serum vitamin B12 levels to detect anemia, and
monitor albumin and pre-albumin levels to determine if protein
supplementation is needed.
• Provide comfort measures and administer analgesics as ordered.
• Frequently turn the patient and encourage deep breathing to prevent
pulmonary complications, to protect skin, and to promote comfort.
• Maintain nasogastric suction to remove fluids and gas in the stomach
and prevent painful distention.

70. Contd….
• Provide oral care to prevent dryness and ulceration.
• Keep the patient nothing by mouth as directed to promote gastric
wound healing. Administer parenteral nutrition, if ordered.
• When nasogastric drainage has decreased and bowel sounds have
returned, begin oral fluids and progress slowly.
• Avoid giving the patient high-carbohydrate foods and fluids with
meals, which may trigger dumping syndrome because of excessively
rapid emptying of gastric contents.
• Administer protein and vitamin supplements to foster wound repair
and tissue building
• Eat small, frequent meals rather than three large meals.
• Reduce fluids with meals, but take them between meals.

71. Gastrointestinal Stromal Tumor ‘GIST’
 leiomyoma & leomyosarcoma.
 <1 %
 Rarly cause bleeding or obstruction.
 The origin: Intestinal Cells of Cajal ‘ICC;s’ autonomic nervous system.
 The distinction bw benign & malignant is unclear.
 The larger the tumor & greater mitotic activity, the more likely to
metastases.
 The stomach is the most common site of GIST.

72.  Usually are discovered incidentally on endoscopy or barium meal
 Small tumorswedge resection
 Larger onesgastrectomy

73. Gastric Lymphoma
• Most common primary GI Lymphoma .
• It’s increasing in frequency.
Presentation:
Similar to gastric carcinoma.
May reveal peripheral adenopathy, abdominal mass or spleenomegaly.

74. Diagnosis:
1.EGD
2.contrast GI x-ray.
3.CT guided fine needle biopsy.
Treatment :
1. surgery: total or subtotal gastrectomy with spleenectomy or
palliative resection.
2.Adjunct radiotherapy: may improve 5 year survival
3.Adjunct Chemotherapy: may prevent recurrance.

75. Complications of gastric cancer
Peritoneal and pleural effusion
Obstruction of gastric outlet or small bowel
Bleeding
Intrahepatc jaundice by hepatomegaly
Dumping Syndrome

76. Dumping Syndrome
It occurs when food, especially sugar, moves too fast from the
stomach to the duodenum.
This condition is also called rapid gastric emptying.
It is mostly associated with gastric or esophageal surgery, though it
can also arise secondary to diabetes or to the use of certain
medications
It is caused by an absent or insufficiently functioning pyloric sphincter.

77. References
• https://www.rnpedia.com/nursing-notes/medical-surgical-nursing-
notes/gastric-cancer/
• https://www.medicalnewstoday.com/articles/257341.php
• http://wps.prenhall.com/wps/media/objects/737/755395/gastric_can
cer.pdf
• https://www.healthline.com/health/gastric-cancer
• https://www.mayoclinic.org/diseases-conditions/stomach-
cancer/symptoms-causes/syc-20352438
• https://www.webmd.com/cancer/stomach-gastric-cancer#1

78. Contd…
• https://www.nhs.uk/conditions/stomach-cancer/
• https://en.wikipedia.org/wiki/Stomach_cancer
• https://www.cancercenter.com/stomach-cancer/learning/
• https://www.cancer.org/treatment/treatments-and-side-effects/complementary-
and-alternative-medicine/complementary-and-alternative-methods-and-
cancer/kinds-of-treatment.html
• https://journals.rcni.com/cancer-nursing-practice/an-overview-of-gastric-cancer-
and-its-management-cnp2011.07.10.6.31.c8624
• SethiDeepak.medicalandsurgicalnursingI&II.1ed.vol1.newdelhi:jaypee
publications;2016
• TortoraGerard.principles of anatomy and physiology.12ed,vol 2:john wiley &
sons,inc;2009
• SuddharthBrunners.Textbook of Medical and Surgical
Nursing.12ed.vol2.Southasian.elseiver publications;2011