CA Stomach overview

8/14/2019 CA Stomach overview

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Ca Stomach

Dr Shafiq Chughtai

Resident Surgeon

SU II , Holy Family Hospital

Rawalpindi

[email protected]


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Incidence

Men > Women , 2:1

USA 10 ,UK 15 , Europe 40 ,

Japan 70 per 100,000 population.

Marked variation world wide indicates a strong environmental

factor in this disease.


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Contd.

6th commonest cause of cancer deaths

world wide.3rd GI malignancy after

pancrease and colorectal Ca.

Incidence falling at 1% per yeardropped

to 1/3 in past 30 yrs

Carcinoma of body & distal stomach

decreasing.

Gastro-esophageal junction increasing.


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Cancer in upper GI tract


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Aetiology (Intestinal type)

Pelayo-Correa model.


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Underlying mechanism for these histological

changes are the genetic mutations

involving :

p53.

RAS oncogene.

HER/neu gene.


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Risk Factors

1 Diet Spiced , salted , pickled food , BBQ food,animal fat consumptions , nitrates consumption, protien malnutrition and alcohal.

2 InfectionsH-pylori , viral infections

3 Congenital HNPCC , Familial adenomatous polyposis,Blood group A.

4 Others Partial gastrectomy , atrophic gastritis ,pernicious anemia , gastric polyp.


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PathologyFinnish / DIO /Lauren Classification

Intestinal gastric cancer

Diffuse gastric cancer


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Intestinal gastric cancer

Origin from areas of gastric metaplasia.

Early cancer remains localized forminglarge localized masses , metastasis is late.

More common in elderly & males.

Better prognosis.


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Diffuse gastric cancer

Arise from normal gastric mucosa.

Cells lack cohesion spread diffusely in stomach

wall without forming localized masses and withearly metastasis.e.g linitis plastica

Young and female.

Worse prognosis.


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Types of gastric cancer

(I) Histology.

(II) Macroscopic appearance.

(III) Extent of spread.


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(I) Histological subtypes of gastric

cancer

Adenocarcinoma 95%

Primary Gastric Lymphoma 4%

Masenchymal tumors 1%


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(II) Macroscopic appearence

Intraluminal (polypoid and fungating)

Intramural (ulcerative or scirrhus )


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(III) Extent of spread

Early gastric cancer

Late gastric cancer


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Early gastric cancer is when cancer

involve the mucosa or submucosa

irrespective of nodal involvement

Advanced gastric cancer is when thecancer involves the muscularis propria


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Early gastric cancerJapanese classification


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Advanced Gastric CancerBorrmann classification


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Contd.

Type 3 and 4 carry the worst prognosis.


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Spread

Direct spread

Lymphatic spread

Blood borne metastasis

Trans peritoneal spread


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Direct spread

Depending upon the location

EsophagusLesser and greater omentum

Liver and pancrease

spleen

Transverse colon


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Lymphatic spread


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Blood Borne Spread

Lungs

Liver

Bones


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Trans peritoneal (P)

Extensive involvement means incurablity.

Blummer shelf / drop metastasis

Krukenberg tumor , Sister Joseph nodule.


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Staging

TNM classification

T1 Mucosa and submucosa

T2 Muscularis propia

T3 Serosa

T4 Surrounding structures


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Nodes

N0 No metastasis to reginal lymph nodes

N1 Nodal metastasis (perigastric) within 3cm of primary tumor

N2 Nodal metastasis >3 cm from primarytumor


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Metastasis

M0 No metastasis

M1 Distinct metastasis


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TNM Staging


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Clinical features

Early symptoms

Late symptoms


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Early symptoms

Non specific & mimic APD

Dyspepsia , indigestion , post parindialfullness , maliase

Will respond to PPIs and H2 blockers.


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Late symptoms

Anorexia & Weight loss.

Dysphagia ---cardia involvement

Vomiting----due to gastric outlet

obstruction.contd


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Contd.

Anemia ---iron deficency type , ch.blood

loss (30%).

Heamatemeisis and malena----acute

bleed from malignant ulcer.


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Signs

GPE---wasting , pallor , jauindice

Neck---virchow node , trosiers sign

Chest---basal consolidation / pl.effusion ,

Mets.contd.


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Contd.Abdomen

Malignant ascites ,

Hepatomegally.

Mass epigastrium , visible peristalasis .

Succusion splash,

DRE / Pelvic Mass on examination(krukenberg / drop metastasis)


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Investigation

Blood CP Anemia

CXR

LFTs and albumin

Electrolytes (hypochaloremic metabolic alkalosis)


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Cardiac and Pulmunary status of the

patient should be assessed.

Echo , ECG , PFTs .


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Investigations

Upper GI Endoscopy

Direct inspection (Site & extent )

Multiple biopsies for tissue diagnosis


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Imaging Studies

Barium Meal Examination : Less commonly performed nowadays

Useful in diagnosis of:

large primary tumors

Irregular strictures

Linitis plastica (leather bottle stomach)

Double-contrast upper GI series

Can detect smaller primary lesion


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Imaging Studies

Endoscopic ultrasound

preoperative assessment of

T stage , Sm superficial / deep.

CT / MRI

May show nodal & metastatic spread: N stage & M stage

Influences type of surgical treatment


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T3 N0 OR T3 N1 = II or III A.


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Imaging Studies

Chest Radiograph

Mets into lungs , effusion or basal

consolidation .

Abdominal Ultrasound

Mets into liver, ascites .


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Serology

CA 724 is the only reliable tumor marker.

CEA has specificity of 65%


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Laproscopy

Assess operablity and rule out fixity to

adjuscent structures.

Staging for peritoneal Mets (only reliable

mode) .


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Traetment of early gastric cancer

Aim achieve 2cm clear tumor free

margins

Tumor less then 3 cm ---local resection

Tumor more then 3 cm or type IIa/IIc, D1clearence to be done.


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Treatment of late gastric cancer

Aim---achieve 5cm tumor free clear

margins.

Three steps , gastric resection , nodal

clearance and reconstruction.


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D1 Clearence

Confined to primary group of nodes mainly

along lesser and greater curvature , rt and lt

cardiac nodes , juxtapyloric nodes.

Removal of greater and lesser omentum with

excised stomach.

contd.


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D1


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D2 clearence

D1 + cealaic nodes and the nodes along

its branches namely Lt gastric , hepatic

and splenic nodes.Nodes in splenic hilum

and retropancreatic nodes removed.

May need splenectomy and resection of

body and tail of pancrease.


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D2


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D3 clearence

D1+D2+nodes of porta hepatis , behind

pancreatic head , in root of mesentry ,

along the middle colic and paraaortic

nodes.

May involve partial colectomy , hepatic

lobectomy , subtotal pancreatectomy ,pancreatico duodenectomy.


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D3


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Gastric resection

(I)Total gastrectomy

(II)Subtotal gastrectomy

(III)Esophagogastrectomy


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(I)Total gastrectomy

Tumor involves 2 or all 3 zones of

stomach.

Its diffuse & Bromann type IV ,

irrespective of size.

When proximal distance from the cardia is

less then required length to achieve safe

tumor free margins.


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(II)Subtotal gastrectomy

Done for tumors which are distally placed

in stomach.

Proximal stomach is preserved with its

blood supply.


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SubtotalGastrectomy

Billroth I

Billroth II

Hofmeisters method

Polyas method

Moynihans method

V.Eiselsbergs method

(III)E h t t


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(III)Esophagogastrectomy

Done for tumors of cardia

Reconstruction by intrathoracic

Esophagogastrostomy


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Principle of reconstruction

After doing gastric resection ,

reconstruction is undertaken. If the

primary lesion is considered curative ,

duodenal continuity is established.

If the lesion is non curative duodenal by

pass surgery is done.

C


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Curative resection4 criterias

No hepatic or peritoneal mets.

No serosa involvement.

Resection margins are free from tumor on

H/P exam.

D resection exceeds level of nodalinvolvement.


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Curative resection

Aim --- to restore duodenal continuitybecause of increased nutritional outcome.

Total gastrectomy ---jejunal interposition

reservior

Subtotal gastrectomy---gastroduodenal

anastomosis/bilroth-I

Total gastrectomy


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Total gastrectomy

jejunal interpositions

Subtotal gastrectomy


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bilroth-I/GD anastomosis

Non curative excision


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Non curative excision

Aim In non curative excision , we doduodenal bypass surgery becausegastroduodenal anastomosis has more

chances of obstruction if recurranceoccour.

Total gastrectomy , do loop jejunostomy

or roux en Y loop.Subtotal gastrectomy polya / bilroth II

gastrectomy.

Total gastrectomy


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Total gastrectomy

loop Jej/Roux en Y Loop



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Bill-II / Polya


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Unresectable tumors

Heamatogeneous spread .

Peritoneal spread

Fixity to adjuscent strs. That can not beremoved surgically


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Palliative surgery

Indications are unresectable tumor with

pain , vomiting , dysphagia , bleeding.


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Expanding metallic / plastic stents for

dysphagia if cardia is involved.

Palliative gastrectomy if body / fundus isinvolved.

Teners antecolic gastrojejunostomy if antralneoplasm.


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Teners antecolic gastrojejunostomy


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To summarize the Rx

Chemotherapy


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ChemotherapyCunningham regimen

(ECF)

Epirubicin 50mg/m thrice weekly plus

Cisplatin 60 mg / m thrice weekly infusion

plus

5FU 200mg/m daily by hickman line.


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Radiotherapy

Radiotherapy has no defined role in

gastric malignancy.


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Prognosis

Depends upon stage of the disease at the

time of treatment

Early gastric carcinoma undergoing

curative resection

50-70 % 5-year survival

Advanced gastric carcinoma undergoing

resection

5 % 5-year survival


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Mesenchymal tumors

Smooth muscle leiomyoma and

leiomyosarcoma

Neurogenic---schwanoma

Uncommitted mesenchymal cells or GIST.


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Treatment

Less then 5 cm local resection with 1-2

cm clean margins.

More then 5 cm ---local resection with

nodal clearence.


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Gastric Lymphomas

All are Non Hodgkins type , rarely idHodgkins lymphoma seen in stomach.

Diagnosis is by endoscopy and biopsy.


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Staging

STAGE-I Single lymphnode region.

STAGE-II Two / more lymph node regions on

same side of diaphram

STAGE-III Lymph nodes on both sides of

diaphram

STAGE-IV Disseminated disease.

T


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Treatment

Stage I ---H pylori eradication.it will cure thedisease if the pt is +ve for it.Other wise surgery

is done.

Stage II----gastrectomy with chemotherapy.

Stage III/IV chemotherapy.


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Thank You .

Documents

CA Stomach overview