Gastric cancer BY : IBEANUSI AKACHUKWU CONFIDENCE

Gastric cancer • Stomach cancer begins when cancer cells form in the inner

lining of your stomach. These cells can grow into a tumor. Also called gastric cancer, the disease usually grows slowly over many years.

• It could be:• malignant or benign• primary or secondary

Etiology• Gastric cancer is more common

in patients with pernicious anemia. blood group A. Gastric ulcer . A family history of gastric cancer. Smoking Being overweight or obese

Stomach surgery for an ulcer Epstein-Barr virus infection Working in coal, metal, timber,

or rubber industries Exposure to asbestos Infection with Helicobacter

pylori Long-term stomach

inflammation Had a polyp larger than 2

centimeters in your stomach A diet high in smoked, pickled,

or salty foods

Early gastric cancer Defined as a tumor confined to the mucosal or sub-mucosal layer,

with or without lymph node metastasis

Signs and SymptomsEarly Gastric Cancer

• Asymptomatic or silent 80%• Peptic ulcer symptoms 10%• Nausea or vomiting 8%• Anorexia 8%• Early satiety 5%• Abdominal pain 2%• Gastrointestinal blood loss <2%• Weight loss <2%• Dysphagia <1%

Advanced gastric cancer invasion depth beyond sub-mucosal layer

Signs and SymptomsAdvanced Gastric Cancer

• Weight loss 60%• Abdominal pain 50%• Nausea or vomiting 30%• Anorexia 30%• Dysphagia 25%• Gastrointestinal blood loss 20%• Early satiety 20%• Peptic ulcer symptoms 20%• Abdominal mass or fullness 5%• Asymptomatic or silent <5%

Metastasis

• Blummer shelf: A shelf palpable by rectal examination, due to metastatic tumor cells gravitating from an abdominal cancer and growing in the recto-vesical or recto-uterine pouch

• Krukenberg tumor: A tumor in the ovary by the spread of stomach cancer

• Virchow Lymph nodes: Left Supraclavicular lymph node• Sister Mary Joseph nodule: Periumbilical nodule

Sister Mary Joseph’s node

•

• Adenocarcinoma (95%) : Cancer that begins in the glandular cells.

• Lymphoma (4%) : Cancer that begins in immune system cells .

• Carcinoid cancer(3%) : Cancer that begins in hormone-producing cell.

• Gastrointestinal stromal tumor (GIST) (1%) : Cancer that begins in nervous system tissues of stomach .

The four most common primary malignant gastric neoplasms are:

Borrmann Classification

5 categories• Type I: Polypoid or Fungating• Type II: Ulcerating lesions with

elevated borders• Type III: Ulceration with

invasion of wall• Type IV: Diffuse infiltration• Type V: Cannot be classified

TNM STAGINGPRIMARY TUMOUR (T)

• TX PRIMARY TUMOUR CANNOT BE ASSESSED • T0 NO EVIDENCE OF PRIMARY TUMOUR • TIS CARCINOMA IN SITU: INTRAEPITHELIAL TUMOUR WITHOUT INVASION OF THE LAMINA PROPRIA • T1 TUMOUR INVADES LAMINA PROPRIA OR SUB MUCOSA • T2 TUMOUR INVADES MUSCULARIS PROPRIA OR SUB SEROSA• T2A TUMOUR INVADES MUSCULARIS PROPRIA• T2B TUMOUR INVADES SUB SEROSA • T3 TUMOUR PENETRATES SEROSA • T4 TUMOUR INVADES ADJACENT STRUCTURES

T stage (UICC TNM 2002)

T4

T3

T2a

T1Adjacentstructure

T2b

TNM STAGINGREGIONAL LYMPH NODES (N)

• NX REGIONAL LYMPH NODE(S) CANNOT BE ASSESSED• N0 NO REGIONAL LYMPH NODE METASTASIS• N1 METASTASIS IN 1 TO 3 REGIONAL LYMPH NODES• N2 METASTASIS IN 4 TO 7 REGIONAL LYMPH NODES• N3 METASTASIS IN >7 REGIONAL LYMPH NODES

LN group1 R cardiac2 L cardiac3 Lesser curvature4 Greater curvature5 Suprapyloric6 Infrapyloric7 L gastric artery8 Common hepatic artery9 Celiac artery10 Splenic hilar11 Splenic artery12 Hepatic pedicle13 Retropancreatic14 Mesenteric root15 Middle colic artery16 Paraaortic

N1

N2

TNM STAGINGDISTANT METASTASIS (M)

• MX DISTANT METASTASIS CANNOT BE ASSESSED • M0 NO DISTANT METASTASIS • M1 DISTANT METASTASIS

TNM STAGING STAGING • Stage 0 TIS N0 M0 • Stage 1A T1 N0 M0 • Stage IB T1 N1 M0

T2A/B N0 M0 • Stage II T1 N2 M0

T2a/b N1 M0T3 N0 M0

• Stage IIIA T2a/b N2 M0T3 N1 M0T4 N0 M0

• Stage IIIB T3 N2 M0 • Stage IV T4 N1-3 M0

T1-3 N3 M0 Any T Any N M1

Laboratory tests• Routine Blood Investigations• Liver function tests• Kidney function tests• Flexible Fiber Optic Upper GI Endoscopy & Biopsy• Endoscopic Ultrasonography• CECT Abdomen• Laparoscopy • Laparoscopic Ultrasonography• Rapid Urease Test• Double Contrast Barium Meal• Chest X Ray• Fractional Test Meal(Gastric Acid Studies)• Tumour markers (CEA, Ca19-9)• Fecal occult blood test (FOBT)

• The best way to stage the tumor locally is via endoscopic ultrasound , it gives (80%) information about the depth of tumor penetration into the gastric wall, and can usually show enlarged (>5 mm) perigastric and celiac lymph nodes.

INVESTIGATIONS-ENDOSCOPY• FLEXIBLE UPPER ENDOSCOPY IS THE

DIAGNOSTIC MODALITY OF CHOICE. • DOUBLE-CONTRAST BARIUM UPPER GI

RADIOGRAPHY IS COST-EFFECTIVE WITH 90% DIAGNOSTIC ACCURACY

• THE INABILITY TO DISTINGUISH BENIGN FROM MALIGNANT GASTRIC ULCERS MAKES ENDOSCOPY PREFERABLE

• DURING ENDOSCOPY, MULTIPLE BIOPSY SAMPLES (SEVEN OR MORE) SHOULD BE OBTAINED AROUND THE ULCER CRATER TO FACILITATE HISTOLOGICAL DIAGNOSIS.

• BIOPSY OF THE ULCER CRATER ITSELF MAY REVEAL ONLY NECROTIC DEBRIS.

INVESTIGATIONS-ENDOSCOPY

• WHEN MULTIPLE BIOPSY SPECIMENS ARE TAKEN, THE DIAGNOSTIC ACCURACY OF THE PROCEDURE APPROACHES 98%.

• THE ADDITION OF DIRECT BRUSH CYTOLOGY TO MULTIPLE BIOPSY SPECIMENS MAY INCREASE THE DIAGNOSTIC ACCURACY OF THE STUDY.

• THE SIZE, LOCATION, AND MORPHOLOGY OF THE TUMOUR SHOULD BE NOTED AND OTHER MUCOSAL ABNORMALITIES CAREFULLY EVALUATED.

• EUS CAN GAUGE THE EXTENT OF GASTRIC WALL INVASION AS WELL AS EVALUATE LOCAL NODAL STATUS

Antral cancer bleeding into

the cavity

Cancer in the Antrum of Stomach

Prepyloric Carcinoma

Endoscopic features of gastric cancer

•

Radiologic diagnosis For reasons of cost and availability, radiography may

sometimes be the first diagnostic procedure performedClassic radiography signs of malignant gastric ulcer• Asymmetric/distorted ulcer crater• Ulcer on the irregular mass• Irregular/distorted mucosal folds• Adjacent mucosa with obliterated /distorted area• Nodularity, mass effect or loss of distensibility

Distal GC Proximal GC Linitis plastica

LAPAROSCOPY• LAPAROSCOPY IS RECOMMENDED AS THE NEXT STEP IN THE

EVALUATION OF PATIENTS WITH LOCO REGIONAL DISEASE.• LAPAROSCOPY CAN DETECT METASTATIC DISEASE IN 23% TO

37% OF PATIENTS JUDGED TO BE ELIGIBLE FOR POTENTIALLY CURATIVE RESECTION BY CURRENT-GENERATION CT SCANNING

• Inspect peritoneal surfaces, liver surface.• Identification of advanced disease avoids non-therapeutic

laparotomy in 25%.• Patients with small volume metastases in peritoneum or

liver have a life expectancy of 3-9 months, thus rarely benefit from palliative resection.

Treatment

EMR

Surgical resection

Adjuvant therapy

Palliative therapy

ENDOSCOPIC MUCOSAL RESECTION

• A SUBSET OF PATIENTS WITH EGC CAN UNDERGO AN R0 RESECTION WITHOUT LYMPHADENECTOMY OR GASTRECTOMY.

• THIS APPROACH INVOLVES THE SUB MUCOSAL INJECTION OF FLUID TO ELEVATE THE LESION AND FACILITATE COMPLETE MUCOSAL RESECTION UNDER ENDOSCOPIC GUIDANCE

• EMERGING VARIATIONS OF EMR TECHNIQUES INCLUDING THE CAP SUCTION AND CUT VERSES A LIGATING DEVICE.

• EMR-RELATED COMPLICATION RATES, INCLUDING BLEEDING AND PERFORATION

• TUMOURS INVADING THE SUB MUCOSA ARE AT INCREASED RISK FOR METASTASIZING TO LYMPH NODES AND ARE NOT USUALLY CONSIDERED CANDIDATES FOR EMR

• EMR IS EMERGING AS THE DEFINITIVE MANAGEMENT OF SELECTED EGCS

LIMITED SURGICAL RESECTION

• PATIENTS WITH SMALL (LESS THAN 3 CM) INTRA MUCOSAL TUMOURS AND THOSE WITH NON-ULCERATED INTRA MUCOSAL TUMOURS OF ANY SIZE MAY BE CANDIDATES FOR LIMITED RESECTION.

• SURGICAL OPTIONS FOR THESE PATIENTS MAY INCLUDE GASTROTOMY WITH LOCAL EXCISION.

• THIS PROCEDURE SHOULD BE PERFORMED WITH FULL-THICKNESS MURAL EXCISION (TO ALLOW ACCURATE PATHOLOGIC ASSESSMENT OF T STATUS)

• AIDED BY INTRA OPERATIVE GASTROSCOPY FOR TUMOUR LOCALIZATION.

• FORMAL LYMPH NODE DISSECTION IS NOT REQUIRED IN THESE PATIENTS

R STATUS-CARCINOMA STOMACH• THE TERM R STATUS WAS FIRST DESCRIBED BY

HERMANEK IN 1994, IS USED TO DESCRIBE THE TUMOR STATUS AFTER RESECTION.

• R0 DESCRIBES A MICROSCOPICALLY MARGIN-NEGATIVE RESECTION, IN WHICH NO GROSS OR MICROSCOPIC TUMOUR REMAINS IN THE TUMOUR BED.

• R1 INDICATES REMOVAL OF ALL MACROSCOPIC DISEASE, BUT MICROSCOPIC MARGINS ARE POSITIVE FOR TUMOUR.

• R2 INDICATES GROSS RESIDUAL DISEASE. • BECAUSE THE EXTENT OF RESECTION CAN INFLUENCE

SURVIVAL, THIS R DESIGNATION TO COMPLEMENT THE TNM SYSTEM.

• LONG-TERM SURVIVAL CAN BE EXPECTED ONLY AFTER AN R0 RESECTION; THEREFORE, A SIGNIFICANT EFFORT SHOULD BE MADE TO AVOID R1 OR R2 RESECTIONS

OPERATIVE PROCEDURE

PARTIAL GASTRECTOMY

SUB TOTAL GASTRECTOMY

TOTAL GASTRECTOMY

TOTAL GASTRECTOMY WITH SPLENECTOMY & DISTAL PANCREATECTOMY

EXTENDED LYMPHADENECTOMY

ADJUVENT CHEMO IMMUNO THERAPY

The immune depression encourages the growth of tumor cells in certain patients.

Numerous immunomodulators have been found to enhance T-cell function and stimulate natural killer cells.

Immunotherapy alone has rarely been shown to be effective against residual tumors.

The advantages are greatest in patients with Stage III and IV disease or patients who underwent R0 resection.

Results are mixed

ADJUVENT THERAPY• Rationale is to provide additional loco-regional control.• Radiotherapy- studies show improved survival, lower

rates of local recurrence when compared to surgery alone.

• In unresectable patients, higher 4 year survival with mutimodal tx, in comparison to chemo alone.

CHEMOTHERAPY• Numerous randomized clinical trials comparing

combination chemotherapy in the adjuvant setting to surgery alone did not demonstrate a consistent survival benefit.

• The most widely used regimen is 5-FU, doxorubicin, and mitomycin-c. The addition of leukovorin did not increase response rates.

PALLIATIVE CHEMO THERAPY• Median survival benefit 3 – 6 months• Combination therapy superior• 50% gain improvement in QOL

COMPLICATIONS OF GASTRECTOMY

• LEAKAGE FROM ESOPHAGO JEJUNOSTOMY• FISTULA FROM WOUND/DRAIN SITE• LEAKAGE FROM DUODENAL STUMP• PARA DUODENAL COLLECTIONS• BILIARY PERITONITIS• CATASTROPHIC SECONDARY HAEMORHAGE

LONG TERM COMPLICATIONS• REDUCED CAPACITY• DUMPING• DIARRHOREA• NUTRITIONAL DEFICIENCIES• VITAMIN B12 DEFICIENCY

PREVENTIONEradication of H. Pylori infection in those high risk

population• Chronic gastritis with apparent abnormality (atrophy, IM)

• Post early gastric cancer resection• Family history of gastric cancer• Gastric ulcer

Management of dietary risk factor• Intake adequate amount of fruits, vegetables• Minimize their intake of salty/smoked foods

Tightly follow up those with precancerous condition

Endoscopic or radiologic screening