stomach cancer oncology

2. Introduction
Fourth most common cancer
worldwide
Second most common cause of
cancer death following lung cancer
Large regional difference in
incidence, decreasing worldwide:
Highest in Eastern Asia, lowest in
North America

3. Risk Factors
Helicobacter pylori gastric infection.
Advanced age.
Male gender.
Diet low in fruits and vegetables.
Diet high in salted, smoked, or preserved foods.
Chronic atrophic gastritis.
Intestinal metaplasia.
Pernicious anemia.
Gastric adenomatous polyps.
Family history of gastric cancer.
Cigarette smoking.
Ménétrier disease (giant hypertrophic gastritis).
Epstein-Barr virus.
Familial syndromes (including familial adenomatous polyposis)

4. Oncogenes,
growth
factors/receptors
(intestinal type)
KRAS/BRAF
EGFR
HER2
C-MET

5. Tumour
suppressor
genes
(intestinal
type)
TP53
TP73
APC
Cyclin E/CDKN1B
Beta-catenin/ Wnt signalling

6. Molecular
biology
(diffuse type)
E-cadherin(CDH1)
FGFR2
C-MET
IL-1a

7. Other
oncogenic
signalling
pathway
Hedgehog pathway
Notch Pathway
Transforming growth
(TGF) factor-β pathway

8. PRECANCEROUS
CONDITIONS
CHRONIC ATROPHIC
GASTRITIS
INTESTINAL METAPLASIA
Precancerous lesions Dysplasia/adenoma
Gastric polyps
Hyperplastic polyp
Fundic gland polyp
Chronic gastric ulcer
Ménétrier's disease
Post-resection gastric stump

9. MACROSCOPIC
TYPE
1. Polyp-like
2. Saucer-shaped
3. Ulceated-infiltrating type
4. Diffuse-infiltirating type (linitis plastica)

10. Intestinal type
Histological features:
• Characterized by a predominance of
glandular epithelium with cells similar to
intestinal columnar cells
• Usually sharply demarcated by a pushing
margin (‘expanding type’)
Common clinical features:
• Arises in older patients, located in the distal
stomach, forms Borrmann type I or II, and
metastasizes to the liver
• Mostly corresponds to papillary and tubular
adenocarcinoma in the Japanese
classification

11. Diffuse type
Histological features:
◦ Composed of scattered, poorly cohesive cells or
small clusters of cells with wide and diffuse infi
ltration:
◦ Cells may contain mucus and can show typical signet
ring cell appearance
◦ Usually diffusely spreading with an ill‐demarcated
margin (‘infiltrating type’)
Common clinical features:
◦ Arises in younger patients, located in the proximal
gastric body, forms Borrmann type III or IV, and
metastasizes to the peritoneum
◦ Mostly corresponds to poorly differentiated
adenocarcinoma, signet ring cell carcinoma and
mucinous adenocarcinoma in the Japanese classifi
cation

12. Histological
Forms
1. Adenocarcinoma:
◦ Papillary
◦ Tubular
◦ Mucinous
◦ Signet-cell
2. Squamous cell carcinoma
3. Undifferentiated cancer
4. Cancer that can not be classified

13. A) TUBULARADENOCARCINOMA;
(B)PAPILLARYADENOCARCINOMA.

14. (A) SIGNET-RING-CELL CARCINOMA;
(B) POORLY DIFFERENTIATED ADENOCARCINOMA.

16. Clinical Signs
Local
• Pain
• Dyscomfort
• Dysphagia
General
• Loss of apetite
• Fatigue
• Loss of weight
• Depression
Related to
complications
• Perforation
• Invasion
• Bleeding
• Stenosis

17. For primary
tumour
assessment:
Endoscopy with biopsy is the first
and definitive diagnostic modality
Double contrast barium swallow is
complementary: can be useful for
the diagnosis of linitis plastica
Endoscopic ultrasonography (EUS)
is useful for T staging and diagnosis
of perigastric lymphadenopathy

18. For
assessment of
metastasis:
Computed tomography (CT)
Abdominal ultrasonography
Magnetic resonance imaging (MRI) is
complementary: can be useful to detect liver and
bone lesions
Value of fluorodeoxyglucose‐positron emission
tomography (FDG‐PET) is relatively limited due
to low sensitivity in histologically diffuse tumours

19. Tumour
markers:
CEA,
CA19‐9,
CA72‐4:
Serum levels are associated with
tumour stage and patient survival
No role in screening, but useful
for detecting recurrence and
distant metastasis
CA125,
sialyl Tn
antigens
(STN):
Often elevated in peritoneal
metastasis

20. Treatment: Stage I
◦ Surgical resection with one of the following surgical
procedures:
◦ Distal subtotal gastrectomy
◦ Proximal subtotal gastrectomy or total gastrectomy,
both with distal esophagectomy
◦ Total gastrectomy
◦ Regional lymphadenectomy is recommended with all
of the above procedures. Splenectomy is not
routinely performed.
◦ Endoscopic mucosal resection (EMR) for select patients
with stage IA gastric cancer.
◦ Postoperative chemoradiation therapy or perioperative
chemotherapy for patients with node-positive (T1 N1)
and muscle-invasive (T2 N0) disease.

21. Treatment: Stage II & III
◦ Surgical resection may include one of the following
surgical procedures:
◦ Distal subtotal gastrectomy
◦ Proximal subtotal gastrectomy or total gastrectomy
◦ Total gastrectomy
◦ Regional lymphadenectomy is recommended with all
of the above procedures. Splenectomy is not
routinely performed.[
◦ Perioperative chemotherapy
◦ Postoperative (adjuvant) chemoradiation therapy
◦ Postoperative (adjuvant) chemotherapy

22. Treatment: Stage IV
◦ First-line palliative systemic therapy with:
◦ Palliative chemotherapy
◦ Fluorouracil (5-FU).
◦ Epirubicin, cisplatin, and 5-FU (ECF)
◦ Second-line palliative systemic therapy
◦ Immunotherapy
◦ Second-line treatment for patients with defective mismatch repair
(dMMR) or microsatellite instability-high (MSI-H) tumors
◦ Third-line treatment for patients with programmed death ligand 1
(PD-L1)‒positive tumors
◦ Endoluminal laser therapy, endoluminal stent placement, or
gastrojejunostomy
◦ Palliative radiation therapy may alleviate bleeding, pain, and
obstruction.
◦ Palliative resection is reserved for patients with continued
bleeding or obstruction.

23. THANK YOU
FOR
ATTENTION!