Gastric CancerGastric Cancer

Professor Dr. Professor Dr.

Bedii Berat APAYDINBedii Berat APAYDIN

Epidemiology of Gastric CancerEpidemiology of Gastric Cancer

Gastric ca. is the 13Gastric ca. is the 13thth most common & the 10 most common & the 10thth most most deadly cancer in USdeadly cancer in US

Japan, Chile, China, Iceland & Finland have a Japan, Chile, China, Iceland & Finland have a high rate high rate of incidenceof incidence & death from this malignancy & death from this malignancy

Its Its truetrue incidenceincidence has declined by more than 40 % has declined by more than 40 % in the last 30 years in the US in the last 30 years in the US

Its Its world wide frequencyworld wide frequency has albeit diminished less has albeit diminished less dramaticallydramatically

Decline in mortalityDecline in mortality rate in Japan in the past years rate in Japan in the past years has been the result of has been the result of mass screeningmass screening

LocationLocation of the cancers has shifted from the distal to of the cancers has shifted from the distal to the proximal portion of the stomacthe proximal portion of the stomac

Is 2 times more common in Is 2 times more common in menmen than in women than in women Its Its incidence & mortalityincidence & mortality increase with increase with ageage (>50) (>50)

Risk Factors for Gastric CancerRisk Factors for Gastric Cancer

HeredityHeredity AgeAge GenderGender DietDiet Social habitsSocial habits OccupationOccupation Predisposing conditionsPredisposing conditions H.pyloriH.pylori HypogammaglobulinemiaHypogammaglobulinemia

Risk Factors for Gastric CancerRisk Factors for Gastric CancerHeredityHeredity

The fact that the incidence in Japan, Chili The fact that the incidence in Japan, Chili Iceland & Finland is 5-6 times as great as Iceland & Finland is 5-6 times as great as those in other parts of the world, support those in other parts of the world, support racial differencesracial differences

Certain families have demonstrated Certain families have demonstrated multiple occurences of Gastric cancer: multiple occurences of Gastric cancer: Napoleon BonaparteNapoleon Bonaparte

4 % of patients with gastric cancer have a 4 % of patients with gastric cancer have a family historyfamily history of gastric cancer of gastric cancer

Patients with gastric cancer have Patients with gastric cancer have frequently frequently blood group Ablood group A

Risk Factors for Gastric CancerRisk Factors for Gastric CancerDietDiet

Foods high in Foods high in sodiumsodium such as pickled such as pickled vegetables, salted fishes & meatvegetables, salted fishes & meat

SmokedSmoked foods foods High High fatfat Items containing Items containing nitritenitrite & & nitratenitrate Elevated Elevated zinczinc level in the water level in the water

Gastric cancer is inversely associated with Gastric cancer is inversely associated with consumption of fresh vegetable, citrous fruits, consumption of fresh vegetable, citrous fruits, vitamine C & whole milkvitamine C & whole milk

RefrigerationRefrigeration has contributed to the decline of has contributed to the decline of Gastric CancerGastric Cancer

Risk Factors for Gastric CancerRisk Factors for Gastric CancerSocial HabitsSocial Habits

Cigarette smokingCigarette smokingis associated with an increased is associated with an increased

risk for Gastric Cancerrisk for Gastric Cancer

Risk Factors for Gastric CancerRisk Factors for Gastric Cancer Social & Occupational FactorsSocial & Occupational Factors Lower socioeconomic classLower socioeconomic class Coal mining Coal mining Timber processingTimber processing Rubber productionRubber production FishermenFishermen Ceramic workersCeramic workers Textile workersTextile workers PaintersPainters Asbesto exposure Asbesto exposure have been associated with gastric ca. have been associated with gastric ca.

Risk Factors for Gastric CancerRisk Factors for Gastric Cancer Predisposing ConditionsPredisposing Conditions

Chronic atrophic gastritis & intestinal Chronic atrophic gastritis & intestinal metaplasiametaplasia

Helicobacter pylori infectionHelicobacter pylori infection Gastric polypsGastric polyps Previous gastrectomyPrevious gastrectomy Pernicious anemiaPernicious anemia Hypertrophic gastropathy (Menetrier disease) Hypertrophic gastropathy (Menetrier disease) have been associated with Gastric ca have been associated with Gastric ca

Microscopic PathologyMicroscopic Pathology

With only the rare exceptions of With only the rare exceptions of carcinoids & squamous carcinomas, carcinoids & squamous carcinomas, gastric cancers are all gastric cancers are all adenocanceradenocancer

The WHO’s histologic classification The WHO’s histologic classification recognizes 4 patterns of adenocancer: recognizes 4 patterns of adenocancer:

-- papillar - mucinouspapillar - mucinous - tubular- tubular - signet ring cell - signet ring cell The most widely used histopathologic The most widely used histopathologic

classification is described by classification is described by LaurenLauren

Lauren’s Classification of Gastric ca.Lauren’s Classification of Gastric ca.Intestinal type:Intestinal type: Cells of this type forme Cells of this type forme

glands resembling colonic glands resembling colonic glandsglands

Manifested by Manifested by polipoid mass polipoid mass or ulcerationor ulceration

Occurs usually in Occurs usually in geographic areas where geographic areas where gastric ca incidence is high: gastric ca incidence is high: worldwide distrubition is worldwide distrubition is epidemicepidemic

Associated with Associated with atrophic atrophic gastritis,intestinal gastritis,intestinal metaplasia & with diet metaplasia & with diet induced dysplastic changesinduced dysplastic changes

Occurs more often in Occurs more often in menmen & & in patients in patients over age 60over age 60

Metastasizes to the liverMetastasizes to the liver

Diffuse type:Diffuse type: Is composed of Is composed of

dispersed cells which dispersed cells which are not organized in are not organized in glandular patternglandular pattern

It It infiltrates stomach infiltrates stomach wallwall without forming without forming mass & produces linitis mass & produces linitis plastica plastica

It is endemicIt is endemic It is less associated It is less associated

with dietary factorswith dietary factors It is found It is found in young & in in young & in

womenwomen Has a greater tendency Has a greater tendency

for peritoneal spreadingfor peritoneal spreading

Early Gastric CancerEarly Gastric CancerGastric ca. confined to mucosa or submucosa Gastric ca. confined to mucosa or submucosa

regardless of lymph node involvementregardless of lymph node involvement EGC ranges from 8-25 % in USA & EGC ranges from 8-25 % in USA &

35-50 % all of gastric ca in Japan35-50 % all of gastric ca in Japan 70 % of EGC are well differentiated & 30 % 70 % of EGC are well differentiated & 30 %

are poorly differentiated & lymph node are poorly differentiated & lymph node invasion is less than 5 %invasion is less than 5 %

5 year survival5 year survival is is 99 %99 % when cancer is when cancer is confined to the confined to the mucosamucosa, , 90 %90 % when cancer when cancer is confined to the is confined to the submucosasubmucosa & survival & survival drops to drops to 70 %70 % when when lymph node lymph node involvementinvolvement is present is present

EGC is divided to several types & subtypesEGC is divided to several types & subtypes

Advanced Gastric CancerAdvanced Gastric Cancer Gross morphology of advanced gastric ca. (tumor Gross morphology of advanced gastric ca. (tumor

extending beyond the submucosa) is classified extending beyond the submucosa) is classified by BORMANNby BORMANN

Bormann classification includes 4 distinct gross categoriesBormann classification includes 4 distinct gross categories

(%13) Type 1 (%13) Type 1 polypoid polypoid (%25) Type 2 (%25) Type 2 ulceratingulcerating with sharply defined margins with sharply defined margins (%36) Type 3 combined (%36) Type 3 combined ulcerating & infiltratingulcerating & infiltrating without clear cut marginswithout clear cut margins (%26) Type 4 (%26) Type 4 infiltratinginfiltrating (%11) 4a : superficial spreading(%11) 4a : superficial spreading

(%15) 4b: linitis plastica(%15) 4b: linitis plastica

Symptoms of Gastric CancerSymptoms of Gastric Cancer Diagnosis is not madeDiagnosis is not made until there is an extensive involvement of until there is an extensive involvement of

the gastric wall & adjacent viscera the gastric wall & adjacent viscera Initial symptoms are vague postprandial heaviness & Initial symptoms are vague postprandial heaviness &

epigastric discomfort not different from other dyspeptic epigastric discomfort not different from other dyspeptic symptoms symptoms

AnorexiaAnorexia -especially for beef products & smoking- -especially for beef products & smoking- with weight with weight lossloss (6 kg) are(6 kg) are the most common sign the most common signss

At the beginning, patients complaint from At the beginning, patients complaint from epigastric painepigastric pain which which mimic peptic ulcer & responds transiently to medical therapy, mimic peptic ulcer & responds transiently to medical therapy, persistent ppersistent painain is is aa late complaint late complaint

Constipation frequently results from restricted foodsConstipation frequently results from restricted foods AnemiaAnemia finding findingss (fatigue & weakness) (fatigue & weakness) & & occult bloodoccult blood in the in the

stool are common whereas massive bleeding occurs in less stool are common whereas massive bleeding occurs in less than 5 % of the patientsthan 5 % of the patients

NauseaNausea & & vomitingvomiting occur when distal lesions obstruct pylorus occur when distal lesions obstruct pylorus, , ddysphagiaysphagia occurs when cancer arises from occurs when cancer arises from cardiacardia

Signs of Gastric CancerSigns of Gastric Cancer AnemiaAnemia findings findings PaPalpable abdominal masslpable abdominal mass is common: 50 % is common: 50 % Abdominal tenderness is a rare findingAbdominal tenderness is a rare finding Hepatomegaly suggests metastatic spreadHepatomegaly suggests metastatic spread Peritoneal seedingPeritoneal seeding may cause massive ascites may cause massive ascites

or Krukenberg’s tumor (involvement of ovaries) or Krukenberg’s tumor (involvement of ovaries) or Blummer’s shelf (involvement of Douglas)or Blummer’s shelf (involvement of Douglas)

A A palpable lymph nodepalpable lymph node in the left in the left supraclavicular fossa (Wirchow’s node) & a supraclavicular fossa (Wirchow’s node) & a metastatic deposit to the umblicus (Sister metastatic deposit to the umblicus (Sister Joseph’s nodule) are sings of advancedJoseph’s nodule) are sings of advanced diseasedisease

Laboratory StudiesLaboratory Studies A microcytic A microcytic anemia anemia secondary to chronic GI secondary to chronic GI

bleeding or macrocytic anemia secondary to bleeding or macrocytic anemia secondary to preexisting pernicious anemia can be foundpreexisting pernicious anemia can be found

Abnormal liver function tests suggest liver Abnormal liver function tests suggest liver metastasismetastasis

CEA, CA19-9, CEA, CA19-9, feto protein feto protein levels are levels are commonly elevated commonly elevated

Studies of gastric acid secretion often reveal Studies of gastric acid secretion often reveal achlorhydria or hypochlorhydriaachlorhydria or hypochlorhydria

Serum Serum gastringastrin level is elevated secondary to level is elevated secondary to achlorhydriaachlorhydria

Radiologic StudiesRadiologic Studies Single contrast barium studySingle contrast barium study of the upper GI tract is of the upper GI tract is

the first diagnostic study to evaluate symptoms.This the first diagnostic study to evaluate symptoms.This study detects more than 80% of gastric ca., but it study detects more than 80% of gastric ca., but it frequently misses early ca.frequently misses early ca.

Findings indicating gastric ca. are as follows:Findings indicating gastric ca. are as follows: A mass lesion in the gastric lumenA mass lesion in the gastric lumen An obtructing lesion of the antrum and cardiaAn obtructing lesion of the antrum and cardia An ulcerated mass resembling a bening ulcerAn ulcerated mass resembling a bening ulcer Enlarged gastric foldsEnlarged gastric folds Nondistendible stomachNondistendible stomach Early gastric ca. can be diagnosed by Early gastric ca. can be diagnosed by double-double-

contrast barium studycontrast barium study

Endoscopic EvaluationEndoscopic Evaluation Upper GI endoscopyUpper GI endoscopy enables the direct enables the direct

visualisation,photograpic documentation & visualisation,photograpic documentation & biopsy of gastric lesionsbiopsy of gastric lesions

Visual diagnosis is accurate in 90% of Visual diagnosis is accurate in 90% of patients with gastric ca. but biopsies must patients with gastric ca. but biopsies must be done for be done for histologic confirmationhistologic confirmation

A minimum of A minimum of 6 biopsy samples6 biopsy samples should be should be obtainedobtained

In In infiltrative typeinfiltrative type of gastric ca. diagnosis of gastric ca. diagnosis was made was made by biopsyby biopsy in only 50%in only 50% of patients of patients

Preoperative StagingPreoperative Staging Once the diagnosis of gastric ca. has been

established, the extent of disease & its resectability should be evaluated

CT or MRI scans should be obtained to evaluate hepatic metastasis, extansion of tm into contiguous organs (pancreas, transverse mesocolon)

Endoscopic intraluminal US provides accurate information about the depth of penetration of tm

Laparoscopy can be used to detect small intraperitoneal & liver metastasis not seen on CT

Spread of Gastric CancerSpread of Gastric Cancer

Intramural spreadIntramural spread Direct invasionDirect invasion Metastasis by way of lymphatic Metastasis by way of lymphatic

vesselsvessels Metastasis by way of blood vesselsMetastasis by way of blood vessels Implantation onto peritoneal Implantation onto peritoneal

surfaces surfaces

Treatment of Gastric CancerTreatment of Gastric Cancer Surgical therapy is the only curative treatment 85% of patients are operable In 50% of patients, lesions are amenable to

resection Of the resectable lesions, half are potentially

curable The surgical objective is to remove the tumor, an

adjacent uninvolved margin of stomach, the regional lymph nodes & if necessary portions of involved adjacent organs

Japanese surgeons recommend more agressive lymphadenectomy as a matter of routine in the resection of ca

For 1/3 distal stomach tumors Resection would entail distal gastrectomy (proximal margin should be a minimum of 6 cm from the gross tumor), with en bloc

removal of omentum, a 3-4 cm cuff of duodenum & regional lymph nodes

(N1+N2 LN), LN12, LN13, LN16

For 1/3 middle stomach tumors & multifocal tumors &

linitis plastica

• Total gastrectomyTotal gastrectomy

• Splenectomy (if required)Splenectomy (if required)

• OmentectomyOmentectomy

• N1+N2 lymphadenectomy N1+N2 lymphadenectomy (LN1-12 complete)(LN1-12 complete)

For 1/3 proximal stomach cancer

• Proximal gastrectomy

• Distal esophagectomy (10 cm)

• Pancreas preserved Splenectomy 10)

• LN 1-10

• LN16

Palliative Surgical Therapy

Palliative resection is recommended ifPalliative resection is recommended if

• the stomach is movable & the stomach is movable &

• life expectancy is more than 2 life expectancy is more than 2 monthsmonths

• GastrojejunostomyGastrojejunostomy can be done can be done when resection is not feasiblewhen resection is not feasible