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Carcinoma stomachCarcinoma stomach

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EpidemiologyEpidemiology

2.5% of all cancer related death.

Overall incidence decreasing.

Incidence varies with geographic areas. Highest in Japan, Chile, Cosat rica. 20 fold higher than…..

SE Asia, North America, North Europe, Africa.

2.5% of all cancer related death.

Overall incidence decreasing.

Incidence varies with geographic areas. Highest in Japan, Chile, Cosat rica. 20 fold higher than…..

SE Asia, North America, North Europe, Africa.

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Epidemiology Epidemiology

Mass endoscopy program is high yielding in case of high incidence areas, where 35% of newly detected cases are of Early Gastric Cancer.

Environment plays a important risk factor in causation of Gastric ca.

Mass endoscopy program is high yielding in case of high incidence areas, where 35% of newly detected cases are of Early Gastric Cancer.

Environment plays a important risk factor in causation of Gastric ca.

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Early gastric carcinomaEarly gastric carcinoma

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Risk factors…Risk factors…

H. pylori infection

Gender

Aging

Smoking

Ethnicity

Diet

Tobacco

Obesity

H. pylori infection

Gender

Aging

Smoking

Ethnicity

Diet

Tobacco

Obesity

Previous gastric surgery

Pernicious anaemia

Menetrier’s disease

Inherited cancer syndrome

Family history +

Type A blood group

EBV infection

Previous gastric surgery

Pernicious anaemia

Menetrier’s disease

Inherited cancer syndrome

Family history +

Type A blood group

EBV infection

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Cancer of gastric Cardia…Cancer of gastric Cardia…

Is on rise…

Probably related to Barrett esophagus as also chronic GERD and obesity.

Clinical behavior similar to distal esophageal adenocarcinoma.

Is on rise…

Probably related to Barrett esophagus as also chronic GERD and obesity.

Clinical behavior similar to distal esophageal adenocarcinoma.

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Is there anyone to protect…?Is there anyone to protect…?

Green leafy vegetables

Citrus food

Green leafy vegetables

Citrus food

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Classification Classification

Gastric carcinoma (microscopically Laurenn’s classification)– Intestinal type

– Diffuse type

Gastric carcinoma (macroscopically Bormann’s classification)– Type I (polypoid)

– Type II (fungating)

– Type III (ulcerated)

– Type IV (infiltrative)

Gastric carcinoma (microscopically Laurenn’s classification)– Intestinal type

– Diffuse type

Gastric carcinoma (macroscopically Bormann’s classification)– Type I (polypoid)

– Type II (fungating)

– Type III (ulcerated)

– Type IV (infiltrative)

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WHO classificationWHO classification

Adenocarcinoma    – intestinal type

– diffuse type

Adenocarcinoma    – intestinal type

– diffuse type

Papillary

Tubular

Mucinous

Signet ring cell

Adenosquamous

Squamous cell

Small cell

Undifferentiated

Papillary

Tubular

Mucinous

Signet ring cell

Adenosquamous

Squamous cell

Small cell

Undifferentiated

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Pathogenesis..Pathogenesis..

Multistep progression, from chronic gastritis to intestinal metaplasia, dysplasia, and carcinoma

Multistep progression, from chronic gastritis to intestinal metaplasia, dysplasia, and carcinoma

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Pathogenesis…..diffuse typePathogenesis…..diffuse type

CDH1 mutation : E-cadherin– Familial

– 50% of sporadic type

Methylation of CDH1 promoter.

BRCA2 mutation.

CDH1 mutation : E-cadherin– Familial

– 50% of sporadic type

Methylation of CDH1 promoter.

BRCA2 mutation.

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Pathogenesis…..intestinal typePathogenesis…..intestinal type

FAP individual in Japan

Mutation in β-catenin. MSI

Hyper-methylation of several genes like TGFβ RII, BAX, IGFRII, p16/INK4a.

FAP individual in Japan

Mutation in β-catenin. MSI

Hyper-methylation of several genes like TGFβ RII, BAX, IGFRII, p16/INK4a.

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Others are also there…Others are also there…

Genetic variants of pro-inflammatory and immune response genes specially in H.pylori

IL-1β

TNF

IL-10

IL-8

Toll-like receptor 4 (TLR4)

Genetic variants of pro-inflammatory and immune response genes specially in H.pylori

IL-1β

TNF

IL-10

IL-8

Toll-like receptor 4 (TLR4)

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Morphology -Location Morphology -Location

Gastric antrum.

Lesser curvature.

Gastric antrum.

Lesser curvature.

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Type Type

Intestinal

Diffuse

Intestinal

Diffuse

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Intestinal type- grossIntestinal type- gross

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Intestinal type- microscopyIntestinal type- microscopy

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Intestinal typeIntestinal type

Composed of glandular structures.

Columnar and mucin secreting.

Grow along broad cohesive fronts to form either an – Exophytic mass.

– Ulcerated area.

Composed of glandular structures.

Columnar and mucin secreting.

Grow along broad cohesive fronts to form either an – Exophytic mass.

– Ulcerated area.

Calcification

Stroma of the tumor is heavily infiltrated by neutrophils or histiocytes

Calcification

Stroma of the tumor is heavily infiltrated by neutrophils or histiocytes

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Intestinal type- microscopyIntestinal type- microscopy

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Diffuse type- grossDiffuse type- gross

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Diffuse type- microscopyDiffuse type- microscopy

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Diffuse type-microscopyDiffuse type-microscopy

Extensive fibrosis

Inflammation

Most tumor cells grow individually

Mucin is intracytoplasmic, typical signet ring.

Extensive fibrosis

Inflammation

Most tumor cells grow individually

Mucin is intracytoplasmic, typical signet ring.

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Linitus plastica- leather bottle stomach..Linitus plastica- leather bottle stomach..

Desmoplastic

Diffuse rugal flattening and a rigid, thickened wall

Desmoplastic

Diffuse rugal flattening and a rigid, thickened wall

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C /FeatureC /Feature

Median age- 55 years

Male: female :: 2 : 1

remarkable decrease in gastric cancer incidence applies only to the intestinal type

weight loss, abdominal pain, nausea, vomiting.

Median age- 55 years

Male: female :: 2 : 1

remarkable decrease in gastric cancer incidence applies only to the intestinal type

weight loss, abdominal pain, nausea, vomiting.

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Spread Spread

supraclavicular nodes (Virchow’s node)

periumbilical region --- subcutaneous nodule---- Sister Mary Joseph nodule.

 Locally invades– esophagus, duodenum

– colon, pancreas, spleen

– omentum,

– seeding of peritoneum , lung/liver

supraclavicular nodes (Virchow’s node)

periumbilical region --- subcutaneous nodule---- Sister Mary Joseph nodule.

 Locally invades– esophagus, duodenum

– colon, pancreas, spleen

– omentum,

– seeding of peritoneum , lung/liver

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Virchow’s nodeVirchow’s node

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Sister Mary Joseph noduleSister Mary Joseph nodule

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Kruckenberg tumorKruckenberg tumor

metastases of diffuse or signet ring types to one or both ovaries

metastases of diffuse or signet ring types to one or both ovaries

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Prognosis depends on..Prognosis depends on..

Depth of invasion

Extent of nodal involvement

Distant metastasis

Depth of invasion

Extent of nodal involvement

Distant metastasis

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GASTRIC LYMPHOMA GASTRIC LYMPHOMA

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Epidemiology Epidemiology

Extra-nodal lymphomas --- GI tract

--- the stomach

Allogeneic bone marrow transplant

Organ transplant recipients– MALTomas

– Diffuse large b-cell lymphoma

Extra-nodal lymphomas --- GI tract

--- the stomach

Allogeneic bone marrow transplant

Organ transplant recipients– MALTomas

– Diffuse large b-cell lymphoma

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Pathogenesis Pathogenesis

Preexisting MALT

Pro-lymphomatous lesion like Chronic H.pylori infection

Eradication of the infection with antibiotics

MALToma may turn into DLBCL

Preexisting MALT

Pro-lymphomatous lesion like Chronic H.pylori infection

Eradication of the infection with antibiotics

MALToma may turn into DLBCL

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TranslocationsTranslocations

Translocations are

11;18

1;14

14;18

activation of NF-κB

Translocations are

11;18

1;14

14;18

activation of NF-κB

In DLBCL transformation p53, p16 inactivation are there.

In DLBCL transformation p53, p16 inactivation are there.

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Microscopy Microscopy

Dense lymphocytic infiltrate in the lamina propria

Dense lymphocytic infiltrate in the lamina propria

The neoplastic lymphocytes infiltrate the gastric glands focally to create diagnostic Lymphoepithelial Lesions

The neoplastic lymphocytes infiltrate the gastric glands focally to create diagnostic Lymphoepithelial Lesions

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GISTGIST

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Morphology Morphology

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Carney’s triadCarney’s triad

gastric GIST, paraganglioma, and pulmonary chondroma

gastric GIST, paraganglioma, and pulmonary chondroma