2. Anatomy
ďThe stomach J-shaped. The stomach
has two surfaces (the anterior &
posterior), two curvatures (the greater
& lesser), two orifices (the cardia &
pylorus). It has fundus, body and
pyloric antrum.
3. a. The left gastric artery
b. Right gastric artery
c. Right gastro-epiploic artery
d. Left gastro-epiploic artery
e. Short gastric arteries
The corresponding veins drain
into portal system. The lymphatic
drainage of the stomach
corresponding its blood supply.
10. Risk Factors for gastric cancer
ďDiet
ď nitroso compounds
ď low fruit/vegetable, high fried foods/processed meat
ď High salt intake
ďObesity
ďSmoking (HR 2-3)
ď? Alcohol
ďH. Pylori
ďLow socioeconomic status
ďHereditary diffuse gastric cancer
ď 40-67% lifetime risk for men, 60-83% for women
ďImmigrants from endemic areas
ď maintain native country risk, risk to offspring similar to new homeland
11.
12.
13.
14.
15. Precursors of Gastric Cancer
ďAdenomatous polyps
ďChronic atrophic gastritis
ďPernicious gastritis
ďMenetriesâs disease
ďPrevious gastric surgery for non- cancerous
conditions
18. Signs
ďPalpable abdominal mass: most common physical
finding
ďIf cancer spreads via lymphaticsâŚ
ďLeft supraclavicular node (Virchowâs)
ďPeriumbilical node (Sister Mary Joseph)
ďLeft axillary node (Irish)
ďEnlarged ovary (Krukenberg's tumor)
ďAscites
19. Investigations
ďRoutine blood examination
low hemoglobin , high ESR
ď stool examination for occult blood
ď gastric function test - will reveal gross hypo / achlorhydria
ď Endoscopy â helpful in diagnosing early cases and taking biopsy
ď Ultrasonography - helps in assesing thickening of agstric wall, local
invasion, peritoneal involvement , ascitis
ď CT scan - extent of the disease , lymph node involvement , liver metastasis
ď Barium studies
ď Staging laproscopy
20. Diagnosis
ďEndoscopy
ďGold standard
ďSingle biopsy from ulcer -> sensitivity ~ 70%
ďSeven biopsies from ulcer -> sensitivity >98%
ďBrush cytology increases sensitivity of single biopsies,
aid in multiple biopsies unclear
21. Preoperative Staging
ďAbdominal / pelvic CT scanning
ďEndoscopic ultrasound (EUS)
ďDepth of the tumour
ďEnlarged perigastric/coeliac lymph nodes
22. Endoscopic ultrasound
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.
23.
24. Barium studies
ďFalse negative in as many as 50% of cases
ďSensitivity as low as 14% in early cases
ďMay be superior to EGD for linitis plastica
ďEGD may be normal while âleather-bottleâ will be
apparent on radiograph
27. Malignant Neoplasms of the Stomach
Primary
Adenocarcinoma (94%)
Lymphoma (4%)
Malignant GIST (1%)
Haematogenous spread
Breast
Malignant melanoma
Direct invasion
Pancreas; Liver; colon; ovary
28. Staging of Gastric Cancer
ďTwo systems:
ďJapanese classification (more elaborate and anatomic
based)
ďWestern: developed by American Joint Committee on
Cancer (AJCC) and International Union Against
Cancer (UICC) -- more widely used
ďTumors at GE junction of in cardia of stomach
within 5cm of GE junction
ďClassified using esophageal staging
29. Gastric carcinoma
CLASSIFICATION
ďDepth of invasion
ďEARLY GASTRIC CA - mucosa & submucosa
ďADVANCED GASTRIC CA - into or through
muscularis propria
ďMacroscopic growth pattern â Ming classification
ďExpanding
ďInfiltrative - "linitis plastica"
ďHistologic subtype
ďIntestinal
ďDiffuse (gastric); poorly differentiated; "signet ring"
cells
30. Gastric carcinoma
CLASSIFICATION
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
Lauren Classification:
1. Intestinal type (53%)
2. Diffuse type (33%)
3. Unclassified (14%)
Ming Classification:
1. Expanding type (67%)
2. Infiltrative type (33%)
31.
32. Histologic type:
1. Papillary
2. Tubular
3. Mucinous
4. Signet ring
Mode of spread:
1. Direct
2. Lymphatic
3. Hematologic
4. Transcoelomic route
33.
34.
35. Linitis Plastica
ďDiffuse-type gastric cancer
ďTumor often infiltrates the submucosa and
muscularis propria
ďSuperficial biopsies may be falsely negative
ďCombination of strip and bite biopsy needed if
suspicious for linitis plastica
37. Staging workup
ďBiopsy
ďImaging
ďCT: evaluates for metastases (M stage)
ď 20-30% with negative CT have intraperitoneal disease at
laparatomy
ď Accuracy of 50-70% for T stage
ď Slightly worse accuracy for N stage compared to EUS
ďEUS: most reliable nonsurgical method to evaluate
depth of invasion
ď More accurate than CT for T stage
ď 65-90% accurate for N stage
38. Staging workup
ďPET
ďMore sensitive than CT for detection of distant
metastases.
ďAlso useful for detecting LNs
ďNegative PET not helpful- even large tumors can be
falsely negative if metabolic activity low.
ď Most diffuse gastric cancers (signet ring) are not FDG avid
39. Staging workup
ďSerologic markers
ďCEA, CA-125, CA 19-9, CA 72-4 may be elevated but
have low sensitivity/specificity
ďNone are diagnostic
ďPreoperative elevation in markers usually pretends high
risk of adverse outcome
ďNo serologic finding should exclude surgical
consideration
43. Treatment
ďLocoregional (stage I-III) disease
ďPotentially curable
ďmultidisciplinary evaluation and consideration of
surgery
ďAdvanced (stage IV) disease
ďPalliative therapy
ďStudies indicate longer survival and better quality of life
with systemic treatment
44. Surgery
The extent of gastric resection depends on:
- tumor size
- location
- depth of invasion
- histological type
45. Treatment
ďComplete surgical resection with removal of LNs
(only chance of cure)
ďPossible in < 1/3 of cases
ďSubtotal gastrectomy for distal carcinomas, total or
near-total for proximal masses
ďReduction of tumor bulk (palliative)
ďChemotherapy (cisplatin + 5-FU or irinotecan)
ď Partial response in 30-50% of patients
ďRadiation (for pain control, no mortality benefit with
XRT alone)
46.
47. The Japanese Research Society for Gastric Cancer
The 16 lymph node locations were classified into 4
concentric groups: N1, N2, N3, N4
Periepigastric Extraepigastric
48. What is the ideal extent of
lymphadenectomy ?
D0- removes less than all relevant N1 nodes
D1- removes N1 nodes only
- Lt and Rt cardiac
- Lt and Rt gastro-epiploic
- Sub and Supra pyloric
D2- removes all N1 and N2 nodes
- Lt gastric
- Common hepatic
- Celiac
- Splenic hilum and along splenic artery
D3- removes all N2 and N3 nodes
49. The residual tumor (R) classification
The absence or presence of demonstrable residual
tumor after conclusion of the treatment (UICC)
R0 resection -no demonstrable residual tumor
R1 resection- microscopically demonstrable
residual tumor (e.g. diseased
residual margin)
R2 resection â macroscopically visible tumor
Distinction between primary palliative intervention
(R1&R2) vs. potentially curative ones (R0)
50. Prognosis
Stage TNM Features
% of
Cases*
% 5-year
survival*
0 TisN0M0 Node negative; limited to mucosa 1 90
IA T1N0M0
Node negative; invasion of lamina propria or
submucosa 7 59
IB T2N0M0 Node negative; invasion of muscularis propria 10 44
II
T1N2M0 Node positive; invasion beyond mucosa but
within wall 17 29T2N1M0
T3N0M0 Node negative; extension through wall
IIIA
T2N2M0
Node positive; invasion of muscularis propria
or through wall
21 15
T3N1-2M0
IIIB T4N0-1M0
Node negative; adherence to surrounding
tissue 14 9
IV T4N2M0
Node negative; adherence to surrounding
tissue 30 3
Any M1 Distant Metastases
** Data from American Cancer Society
51. Pharmacologic Therapy
ď Cisplatin + epirubicin & infusional 5-FU or + irinotecan
ďĄ Complete remissions are uncommon.
ďĄ Partial responses in 30-50% of cases are transient.
ďĄ Overall influence on survival has been unclear.
ď Adjuvant chemotherapy alone following complete
resection has only minimally improved survival.
ď Perioperative treatment and postoperative chemotherapy
+ radiation therapy reduce the recurrence rate and
prolongs survival.
52. Treatment: Supportive:
ďNutrition (jejunal enteral feedings or total parenteral
nutrition),
ďCorrection of metabolic abnormalities that arise from
vomiting or diarrhea
ďTreatment of infection from aspiration or spontaneous
bacterial peritonitis.
ďTo maintain lumen patency, endoscopic laser
treatment or stenting for palliation.
53. Screening
ďMostly barium studies, EGD is concerning findings
ďSome use serum pepsinogen testing for high risk with EGD
confirmation
ďH. pylori: sensitivity 88%, specificity 41% (Japan)
ď 5-year survival 74-80 in screened group, 46-56% for non-
screened group.
Editor's Notes
HDGC: 40-67% lifetime risk for men, 60-83% for women