INCIDENCE GLOBAL STATISTICS 640600 MEN 349000 WOMEN 50%
adavanced carcinoma CA CANCER J.CLIN 2011
Slide 3
Distal cancer Increase in proximal cancers Incidence remains
high in Japan Their cure rates better due to screening/
survellance/early detection
Slide 4
Age Average age of onset 55 yrs
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Etiology Diffuse cancer Proximal & hereditary Intestinal
type Distal cancers younger Endemic/ inflammatory changes with
Helicobacter pylori infection
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DIET Linked to High ingestion of
Redmeat/cabbage/spices/fish/smoked Salt preserved/high carohydrates
Low ingestion of fruits vegetables Fat /protein/vitamins A,C,E
Slide 7
Gastric Cancer Dietary/Lifestyle Factors Carl-McGrath S, et al.
Cancer Therapy (2007).
Slide 8
Helicobacter pylori infection Increased risk HP organism found
in 89% intestinal type/32% with diffuse type Trials in eradicating
HP infection
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Heredity & Race African/Asian/Hispanic American >risk
Whites< risk
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Anemia pernicious anemia 3to18 times > risk Achlorhydria
Atrophic gastritis
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Previous Gastric resection Gastric stump ca > 15 to 20 yrs
Alakaline bile/dysplasia of gastric ca/ elevated gastrin levels
> carry poor prognosis
Slide 12
Mucosal dysplasia Grade I to III High grade dysplasia
>marker for future gas.ca Intestinal metaplasia/ replacement of
Glandular epithelium> intestinal type
Slide 13
Gastric Cancer Correa Sequence- pathophysiology Vogelgram of
CRC http://www.hopkinscoloncancercenter.org Increasing risk Normal
Chronic gastritis Mucosal atrophy Intestinal metaplasi a
Intestinal-type carcinoma Dysplasia Potentially reversible Not HGD
Hartgrink HH, et al. Lancet (2009).
Slide 14
Gastric polyps FAP ( Familial adenomatous polyposis) Have >
incidence of gas.ca/advised endoscopy/ survellence Hyper
plastic>do not have malig.potential
Laurens Intestinal type(53%) Good prognosis HP infection
Diffuse type(33%) Bld group A,Familial, signet ring,poor
differentiation, younger bad prognosis
Slide 21
Japanese classification Early gastric > mucosa+ submucosa+
or - nodes 1 protruded cure rate >95% 2 superdicial 3
Excavated
Slide 22
Slide 23
Advanced gastric ca Muscularis+serosa + or nodes Borrmans
classification I single polypoid II ulcerated ca + clear margin
III,,,,,, + with out clear margin IV diffuse & V
unclassified
Slide 24
Slide 25
MINGS classification Expanding Infiltrative
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WHO Histological( Microscopic) Adeno ca>papillary,tubular
mucinous,signet Adenosuamous Squamous undifferentited
Slide 27
Siewert classifiaction Proximal gas.ca TypeI Ca of GE (
Barrets) TypeII With in 2 cms Squamo columnar junc TypeIII
Subcardial
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Location of cancers Distal >40% Proximal>35%
Body>25%
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Spread Local Ulcerative> gsatric wall> serosa
schirrous>submucosa/muscularis Lymphatic Virchows node ( left
supraclavicular ) Left axillary (Irish node) Blood spread>liver
40%Lung 40% Sclerotic bone mets/carcinomatous meningitis
Slide 30
contd Peritoneum 10% seedling of peritoneal surfaces
Umbilicus/falciform(sis Mary joseph nodule) Krukenberg>mets to
ovary Blumer shelf ( rectal shelf in men)
Investigations CBC/LFT/Chest x-ray EGD(
esophagogastroduodenoscopy) USG/EUS(endo ultrasound) CT Diagnostic
lap
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Staging TNM Tx cant be assessed T0 No eveidence of tumour Tis
in situ T1 lamina propria or submucosa T2 a muscularis propria T2
binvades subserosa T3 invades serosa T4 adjacent structure
Slide 35
Gastric Cancer Staging Systems TNM: most important clinical
prognostic factor http://www.hopkins- gi.org
http://www.medscape.com/viewarticle/543068_3
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Nodes Nx cant be assessed No no nodes N1 1-6 nodes N2 7-15
nodes N3 > 15 nodes
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Meatastasis Mx Mets cant be assessed Mo No mets M1 distant
mets
Slide 38
Management Surgery > Curative 1 Endoscopic mucosal resection
2 Subtotal gastrectomy distal 2cm & proximal 5 cm
clearance(Billroth II) 3 Total gastrectomy (Roux en y)
Chemo for advanced ca ECF epirubicin/5 FU/Doxorubicin EOX
epirubicin/0xaliplatin/capecitabine DCF
Docetaxel/cisplatin/5FU
Slide 45
Radio therapy-Role Helpful in palliation for unrsectable
tumors(4000cgy 4wks) IORT (tumour bed)
Slide 46
Prognosis Early 5 yr survival 70- 90% Advanced ca less than 20%
Recurrence with in 3 yrs
Slide 47
Gastric lymphoma Primary- elderly/NHL-B cell type Mucosal
associated lymphoid tissue (MALTOMA)/H.pylori Loss of appetite/pain
abdomen/wt loss Mass abdomen Associated SLE/HIV/Ch gastritis
etc
treatment Treat HP infection Surgery for obstruction Chemo same
as NHL
Slide 50
GIST-gastroinestinal stromal tumor Non epithelial /equal sex
incidence 50-70 yrs Arises from interstitial cell of cajal Treat
surgery Chemo sunitinib imatinib