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Gastric cancer

By:Alireza kamrani poor

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Gastric tumor

Malignant ( 93%)

Benign (7%)

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PrimaryAdenocarcinoma (95%)

Lymphoma (4%)

Malignant GIST (1%)

Haematogenous spread

Breast

Malignant melanoma

Direct invasion

Pancreas; Liver; colon; ovary

Malignant Neoplasms of the Stomach

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Adenocarcinoma -Epidemiology

• Incidence in USA/western Europe

• Leading cause of death in Asia/Eastern Europe

• Elderly ( 6-7th decade )

• Men/women : 2

• Low SE status

• Black

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Risk factor

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H.Pylori

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Gastric Cancer Genetic Mutations

• Deletion or suppression of p53

• Overexpression of COX-2 ( more invasive )

• CDH1 ( e-cadherin )(hereditary diffuse cancer)

(prophylactic gastrectomy )

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Macroscopic classificationBorrmann classification

Polypoid

Fungating

Ulcerative

Scirrhous

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Gastric CancerHistology –Lauren Classification

Intestinal (53%)

Diffuse ( 33%)

Unclassified (14%)

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Proximal Gastric Cancer Distal Gastric Cancers

Includes GEJ, Tumors of the Cardia

Includes Body and Antrum

Rapidly increasing incidence in the west

World wide incidence is declining steadily

Mainly diffuse type Mainly intestinal type

M:F = 1:1 M>F

Younger age Older age

More aggressive Less aggressive

More in the developed countries

More in developing countries

Not associated with H. pylori Associated with H. pylori

Associated with GERD Associated with atrophic gastritis

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Gastric Cancer TNM staging

Tis Intaepithelial tumour

T1 Tumour invades LP or submucosa

T2 Tumour invades muscularis propriaor subserosa

T3 Tumour penetrates serosa without invasion of adjacent structures

T4 Tumour invades adjacent structures

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T Staging

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N0 No regional lymph node metastases

N1 Metastasis in 1 to 6 regional lymph nodes

N2 Metastasis in 7 to 15 regional lymph nodes

N3 Metastasis in more than 15 regional lymph nodes

M0 No distant metastasis

M1 Distant metastasis

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.

Stage 0 Tis N0 M0

Stage IA T1 N0 M0

Stage IB T1 N1 M0

T2a/b N0 M0

Stage II T1 N2 M0

T2a/b N1 M0

T3 N0 M0

Stage IIIA T2a/b N2 M0

T3 N1 M0

T4 N0 M0

Stage IIIB T3 N2 M0

Stage IV T4 N1–3 M0

T1–3 N3 M0

Any T Any N M1

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• D1: stations 3-6

• D2: stations 1,2, 7,8 and 11

• D3: stations 9, 10 and 12

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Symptom Percent

Weight loss 62

Abdominal pain 52

Nausea 34

Dysphagia 24

Melena 20

Early satiety 18

Ulcer-type pain 17

anorexia ?

symptoms

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- Normal PH/E except for metastasis.

- The most common metastatic distribution is to the liver, peritoneal surfaces, and nonregional or distant lymph nodes. Less commonly, ovaries, central nervous system, bone, pulmonary or soft tissue metastases occur.

liver :

• palpable liver

• Jaundice

• ascites

Physical exam

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Paraneoplastic signs

Acanthosis nigricans

•

trousseau sx

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• left supraclavicular adenopathy : Virchow's node

• periumbilical nodule :Sister Mary Joseph's node

• left axillary node : Irish node

• Peritoneal spread can present with an enlarged ovary Krukenberg's tumor or a mass in the cul-de-sac on rectal examination Blumer's shelf .

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• Atrophic gastritis

• Gastric epithelial polyps

• Gastric metaplasia and dysplasia

• Pernicious anemia and gastric carcinoid tumors

• Postgastric surgery

• Familial adenomatous polyposis and hereditary nonpolyposis colorectal cancer (Lynch syndrome)

screening

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- Age > 45 or

- Alarming sign or

- Family history

further evaluations

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further evaluations

• Ct scan

• Endoscopic ultrasonography (EUS)

• Pet scan

High risk for surgery

High risk for metastase

• Laparoscopy

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Surgical Resection & Adequate Lymphadenectomyis the only curative treatment

except

•Metastases

•Co-morbid

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Treatment

• Emr

• Total gastrectomy

• Sub total gastrectomy

• Adjuvant therapy

• Billroth 1 (gastroduodenostomy)

• Billroth 2(gastrojejunostomy)

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www.themegallery.com

Definition- EGC

• EGC is a cancer in which tumor invasion is confined to the mucosa or submucosa (T1) regardless of the presence of lymph node metastasis.

Japanese Gastric Cancer Association, “Japanese classification of gastric carcinoma—2nd English edition,” Gastric

Cancer, vol. 1, no. 1, pp. 10–24, 1998.

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Subtotal Gastrectomy

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Total Gastrectomy

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GASTRIC LYMPHOMA

• 5% of all primary gastric neoplasm's

• 2 different types of lymphoma

– Part of systemic lymphoma with gastric involvement (32%)

– Part of primary involvement of the GIT (MALT Tumors) ( most common )( b cell non hodgkin lymphoma )

• Risk factors

– HP due to chronic stimulation of the MALT

– In early stages of disease Rx of HP leads to regression of the disease

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www.themegallery.com

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GASTROINTESTINAL STROMAL TUMORS

• GI mesenchymal tumors

• asymptomatic, found by chance (ulceration, bleeding weight loos)

• Hematogenous metastase

• treatment:

resection(≥1cm , sypmthomatic )

chemotherapy if unresectable ( imatinib) ( CD34 & CD117)

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Gastric Polyps

• benign

• rarely produce symptoms

• types:

hyperplastic

adenomatous

Heterotopic

Inflamatory

hamartomatous polyp

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www.themegallery.com

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Gastricpolyp

symptomatic

asymptomatic

surgery

>2cm

<2cm adenomatous

Non adenomatousfollow

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GASTRIC LIPOMA

– Asymptomatic

– On routine endoscopy

– Require no treatment ( unless symptomatic )

Squeeze sign

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