Gastric cancer seminar presentation covered the following topics in 3 sentences or less: The presentation discussed the anatomy, blood supply, lymphatic drainage and histology of the stomach. Risk factors, clinical presentation, diagnostic tools and staging of gastric cancer were explained. Surgical treatment options including endoscopic resection, gastrectomy and lymph node dissection were summarized along with reconstruction methods.

1. Gastric cancer
Seminar presentation
-Dr.Bajrang Bawliya

2. Carcinomastomach
• Clinical
Presentation
• Diagnosis
• Staging
• Treatment
• Screening

5. Anatomy
The 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.

6. 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.
Blood supply and Lymphatic Drainage

7. Histology
Consist of four layers
1.serous layer
2.muscular layer
3.submucous layer
4.mucous layer

8. PHYSIOLOGY
Function:
1. Digestion of food, reduce the size of food
2. Acts as reservoir
3. Absorption of Vit. 12,iron and calcium
Stimulant of Gastric secretion:
1. Gastrin -----> (+) parietal cell
2. Acetylcholine (vagus) ---> (+) gastric cells
3. Histamine (mast cells) ---> parietal &chief cells

10. Spectrum of gastric cancer
Proposed progression:
chronic gastritis  chronic atrophic gastritis 
intestinal metaplasia dysplasia
 adenocarcinoma

11. RiskFactors for gastriccancer
• Diet
- Nitroso compounds
- Low fruit/vegetable, high fried foods/processed meat
- High salt intake
• Obesity
• Smoking
• ? Alcohol
• H. Pylori
• Low socioeconomic status
• Hereditary diffuse gastric cancer
- 40-67% lifetime risk for men, 60-83% for women
• Immigrants from endemic areas
- maintain native country risk, risk to offspring similar to new homeland

12. Precursors of GastricCancer
• Adenomatous polyps
• Chronic atrophic gastritis
• Pernicious gastritis
• Menetries’s disease
• Previous gastric surgery for non-
cancerous conditions

17. Symptoms at presentation
Dysphagia: more commonwith proximal gastric
tumors
Occult GI bleeding very common, overtbleeding
<20%.

18. Signs
• Palpable abdominal mass: most common
physical finding
• If cancer spreads via lymphatics…
• Left supraclavicular node (Virchow’s)
• Periumbilical node (Sister MaryJoseph)
• Left axillary node (Irish)
• Enlarged ovary (Krukenberg's tumor)
• Ascites

21. Differential Diagnoses
•Acute Gastritis
•Atrophic Gastritis
•Bacterial Gastroenteritis
•Chronic Gastritis
•Esophageal Cancer
•Esophageal Stricture
•Esophagitis
•Malignant Neoplasms of the Small Intestine
•Non-Hodgkin Lymphoma (NHL)
•Peptic Ulcer Disease
•Viral Gastroenteritis

22. Investigations
Routine blood examination-low hemoglobin , high ESR
•Carcinoembryonic antigen (CEA) is increased in 45-50% of cases
•Cancer antigen (CA) 19-9 is elevated in about 20% of cases
• stool examination for occult blood
• gastric function test - will reveal gross hypo / achlorhydria
• Endoscopy– helpful in diagnosing early cases and taking biopsy
• Biopsy of any ulcerated lesion should include at least 6 specimens taken from around the
lesion because of variable malignant transformation.
• Ultrasonography - helps in assesing thickening of gastric wall, local invasion, peritoneal
involvement , ascitis
• CT scan- extent of the disease , lymph node involvement , liver metastasis
• Barium studies
• Staging laproscopy

23. Diagnosis
• Endoscopy
• Gold standard
• Single biopsy from ulcer -> sensitivity ~70%
• Seven biopsies from ulcer -> sensitivity >98%
• Brush cytology increases sensitivity of single
biopsies, aid in multiple biopsies unclear

24. Endoscopicultrasound
Asmall, high frequency ultrasound
transducer incorporated into thedistal end
of the endoscope.
Advantages:
- superior resolution.
- image not compromised byintervening
gases.
-lesion as small as 2-3 mm in diameter can
be imaged.

25. Barium studies
• False negative in as manyas 50% of cases
• Sensitivity as low as 14%in early cases
• May be superior to EGD for linitis plastica
OGD may be normal while “leather-bottle”will be apparent on
radiograph
MOLECULAR STUDIES:-
•Microsatellite instability (MSI) and deficient mismatch repair (dMMR) testing if
metastatic disease is documented/suspected
•HER2-neu and programmed death ligand 1 (PD-L1) testing if metastatic
adenocarcinoma is documented or suspected

26. Stagingworkup
• Biopsy
• Imaging
• CT abdomen pelvis : evaluates for metastases (M stage)
20-30% with negative CT have intraperitoneal diseaseat laparatomy
Accuracy of 50-70% for T stage
Slightly worse accuracy for N stage compared to EUS
• EUS: most reliable nonsurgical method to evaluate depth of
invasion
More accurate than CT for Tstage
65-90% accurate for N stage

27. Stagingworkup
• PET
• More sensitive than CT for detection of
distant metastases.
• Also useful for detecting LNs
• Negative PET not helpful- even large tumors can
be falsely negative if metabolic activity low.
Most diffuse gastric cancers (signet ring) are not FDG avid

28. Stagingworkup
• Serologic markers
• CEA, CA-125, CA19-9, CA72-4 may be elevated
but have low sensitivity/specificity
• None are diagnostic
• Preoperative elevation in markers usually pretends
high risk of adverse outcome
• No serologic finding should exclude
surgical consideration

31. Malignant Neoplasms of theStomach
Primary
Adenocarcinoma (94%)
Lymphoma (4%)
Malignant GIST(1%)
Haematogenous spread
Breast
Malignant melanoma
Direct invasion
Pancreas; Liver; colon; ovary

32. Stagingof GastricCancer
• Two systems:
• Japanese classification (more elaborate and
anatomic based)
• Western: developed by American Joint Committee
on Cancer (AJCC) and International Union Against
Cancer (UICC) -- more widelyused
• Tumors at GE junction or incardia of
stomach within 5cm of GEjunction
Classified using esophageal staging

33. 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%)

40. 8thAJCCStaging System

41. T1a
T1b
Depth of
tumor
invasion
Number of involved
LN
Presence or absence
of metastatic
disease
TX – Primary tumor
can’t be assessed
T0 – No evidence of
primary tumor
Tis- Carcinoma in situ
Mucosa
Submucosa
Muscularis
propria
Subserosal
CT
Serosa

42. AJCCStaging System

46. 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
R1resection- microscopically demonstrable
residual tumor (e.g.diseased
residual margin)
R2 resection – macroscopically visible tumor
Distinction between primary palliativeintervention
(R1&R2)vs. potentially curative ones (R0)

48. The Japanese Research Society for Gastric Cancer
The 16 lymph node locations were classified into 4
concentric groups: N1,N2, N3, N4
Periepigastric Extraepigastric

50. What is the ideal extent of
lymphadenectomy ?
D0- removes less than all relevant N1nodes
D1- removes N1nodes only
- Lt and Rt cardiac
- Lt and Rt gastro-epiploic
- Sub and Supra pyloric
D2- removes all N1and N2nodes
- Lt gastric
- Common hepatic
- Celiac
- Splenic hilum and along splenic artery
D3- removes all N2 and N3nodes

52. Total gastrectomy should not as a routine procedure for gastric
adenocarcinoma.
Patients in whom R0 resection can be obtained, a more limited gastric
resection (e.g., proximal esophagogastrectomy or distal subtotal gastrectomy)
provides the same survival result less perioperative morbidity.
Surgery
Endoscopic
sub-
mucosal
resection
Hemi-
gastrectomy
Subtotal
gastrectomy
Total
gastrectomy

55. EMR and ESR
EMR (Endoscopic mucosal resection)
injection of a substance under the targeted lesion to act as a
cushion,
lesion is then removed with a snare or suctioned into a cap and
snared
.
ESR (Endoscopic sub-mucosal resection)
injection of a substance under the targeted lesion to act as a
cushion, submucosa is instead dissected under the lesion with a
specialized knife. This enables removal of larger and potentially
deeper lesions
 higher rates of R0 resections and a lower rate of local recurrence, but
 technically demanding and has more adverse events.

57. Distal 1/3rd tumor :
• Distal gastrectomy
• Hemigastrectomy
• Subtotal
gastrectomy
Middle 1/3rd tumor :
• Subtotal gastrectomy
• Total gastrectomy

58. Proximal 1/3rd tumor :
 Proximal esophago-gastrectomy (if R0 resection possible) but l/t
symtomatic reflux
 Total gastrectomy

61. Extent of lymph node dissection
 D1
Perigastric nodes (station 1-6)
Conservative node dissection
 D2
D1 + left gastric, Common hepatic,celiac & splenic L.N.(7-11)
Extended node dissection
 D3
D2 + Hepato-duodenal ligament, retropancreatic & mesenteric root (12-16)
Super-extended lymphadenectomy
 D4
D3 + para-aortic and para colic LN dissection

62. Extent of nodal dissection D1 v/s D2
most controversial area in gastric cancer management
• Japanese literature
• Increased survival in patients undergoing a D2 dissection, with no increased or
minimal increase in morbidity.
• Non japanese literature
• D2 lymphadenectomy, when compared with a D1 dissection, has increased surgical
morbidity, without a benefit in survival.
• One criticism of the Western data is that although randomized, the D2 group did not
differentiate between patients who had a splenectomy and those who did not.
• Subsequent subgroup analysis of the D2 without splenectomy group has shown
results similar to the Japanese studies, with increased survival and no significant
increase in morbidity.

63. Resectable or not ?
 Involvement of other organ per se does not imply incurability, provided that it
can be removed ….Bailey and love’s short practice of surgery 26th ed.
 Therapeutic nihilism should be avoided &, in low risk patient, an aggressive
attempt to resect all tumor should be made. The primary tumor may be resected en
bloc with adjacent involved organs (eg., pancreas, transverse colon, or spleen)
……Schwartz’Princilpes of Surgery 10th ed.
 Asolitary metastatic nodule in liver is also no indication against curable
resection.
..(CSDT) Current Diadnosis and Treatment, Surgery 14th ed.

64. Steps in Total gastrectomy
Long mid-line incision or b/l subcostal incision (chevron)
Detachment of greater omentum from
colon
anterior layer of mesocolon is dissected
from mesocolonic vessels
Dissect upto inferior border of
pancreas and divide Rt GE vessels
Dissect upto splenic hilum,
ligate Lt. GE & short gastric
dissect lesser omentum
from the undersurface
of the Liver extending
back to the right crus
and mobilizing the right
aspect of G-E junction.
Divide duodenum with GIAstapler

65. close the duodenal stump with
interrupted horizontal 3-0
absorbable mattress sutures,
essentially "dunking“ the
duodenum.
Dissection of porta, hepatic artery,
& celiac axis is completed from
above down
Left gastric artery divided at
its origin f/b clearance of
right crus and celiac axis
dissection of all the tissue
from Lt. crus & paracardial
LNs
Mobilization of esophageal
hiatus by detaching the
peritoneal reflection from
the diaphragm
Divide esophogus sharply by
knife or scissors

66. Reconstruction after surgery
After total gastrectomy Roux-en-Y esophago-jejunostomy
Division of jejunum with GIA
stapler
end-to-side esopago-
jejunostomy

67. full-thickness running
suture
Placement of the
EEAstapler through
the divided loop
Completion of the stapled anastomosis
and closure of the end of the loop with
a stapler.
 Jejunal loop should be at least 40 cm from the subsequent jejunojejunal
anastomosis to minimize esophageal reflux.

68. Alternative reconstruction with
the EEAstapler using a separate
enrerotomy and end-to-end
anastamosis
Jejunal pouch / Omega pouch
Pouch creation can be done safely without
increased morbidity or mortality without
significantly increasing the operative time.
QOL was significantly better in pts with
pouch reconstruction.
Gertler R et al. Am J Gastroenterol 2009; 104(11):2838–51
make the pouch first by two passages of the GIA
stapler and then perform the Esophago-jejunal
anastomosis

69. Completed Roux-en-Yreconstruction
Post-op :
Unless fever or ileus develops,
the patient is allowed ice on the
1st day and can be given nutrient
by the 5th day.
Any concern clinically for
anastomotic leak can be confirmed
by a Gastrografin Swallow, which
is not routine

70. Steps in Subotal gastrectomy
1) Mobilization of the greater
curvature with omentectomy &
division of left gastroepiploic
vessels
2) lnfrapyloric mobilization
with ligation of the right
gastroepiploic vessels
3) Suprapyloric mobilization
with ligation of the right
gastric vessels
4) Duodenal transection
5) D2 lymphadenectomy, with
dissection of the porta hepatis,
common hepatic artery, left
gastric artery, celiac axis, &
splenic artery, and ligation of
left gastric vessels
6) Gastric transection

71. After Subtotal gastrectomy  Loop gastro-jejunostomy (Bilroth II) or
Roux-en-Y gastrojejunostomy
Stomach divided at greater curvature for 6-8 cm by knife (site of future
anastamosis) and then completely divided with GIAstapler
Staple line inverted
with suture
Anticolic Bilroth II
Retrocolic Bilroth II
BilrothII

72. Standard technique for a two-layer, hand-sewn gastrojejunal anastomosis
After placement of corner
sutures, a back row of
interrupted 3-0 silk Lembert
sutures is placed
jejunostomy is made with
cautery
inner layer anastomosis
is constructed in running, full-
thickness fashion with 3-0 PDS
Anterior
row of
interrupted
3-0 silk
Lembert
sutures

73. After Subtotal gastrectomy  Roux-en-Y
Gastrojejunostomy
jejunum is divided with
GIA stapler approx. 20cm
distal to the ligament of
Treitz
end-to-side Roux-en-Y
gastrojejunostomy is
created with a Roux limb
at least 45cm in length to
avoid reflux

74. Laparoscopic resection
Meta-analysis of 5 randomized trials and 18 non –randomized comparisons of
laparoscopic versus open gastrectomy came to following conclusions
 Mean number of lymph nodes retrieved by laparoscopic surgery was
close to that retrieved by open procedure
 Less blood loss
 Lengthier operative times
 Conversion rate – 0 – 3%
 Significantly less postoperative morbidity after a laparoscopic procedure
 No difference in long term survival
Tanimura S et al. Surg Endosc 2008; 22(5):1161–4.
Kawamura H et al. World J Surg 2008;32(11):2366–70
Revised Japanese Gastric Cancer Treatment Guidelines
Laparoscopy-assisted gastrectomy eligible for - stage IAand IB
(T1N1, T2N0) cancers.
Kodera Y et al. J Am Coll Surg 2010; 211(5):677–86

76. Peri-operative Chemotherapy
 MAGIC trial
Randomised controlled study of 503 pts. With stage II or higher gastric cancer that
compared perioperative chemotherapy with surgery alone.
CEF (Cisplatin, Epirubicin, 5-FU) - 3 cycles as neo-adjuvent CT
- 3 cycles as adjuvent CT
5-yr survival, rate of local recurrence & distant metastasis were improved in
CT group
UK National Cancer Institute trial OEX
(Oxaliplatin, Epirubicin, Capecitabine)
longer overall survival than with CEF and decreased incidence of thromboembolic
phenomenon by substituting oxaliplatin for cisplatin

77. Intraperitoneal Chemotherapy (IPC)
 Recurrence following curative resection is likely due
to peritoneal carcinomatosis.
 Systemic CT : blood-peritoneal barrier prevents the
chemotherapeutic agents from achieving their cytotoxic effect.
 IPC : administering high doses of chemotherapy directly to the
peritoneum
whilst reducing the systemic effects.
 HIPC (hyperthermic Intraperitoneal Chemotherapy )
 increased risk of neutropaenia and intra-abdominal abscesses.

81. Adjuvent Radiotherapy
INT(0116) trial demonstrates improvement in DFS and OS with post-operative
chemoradiation than with surgery alone.
Radiotherapy is limited, due to its position near vital organs like kidney spinal cord,
pancreas, liver & bowel.
Stomach itself is highly sensitive, tends to bleed and ulcerate with EBRT.
Intraoperative radiotherapy (IORT)
Takahashi & Abe in 1986, Japan randomized 211 patient IORT (25- 40 Gy) Vs
surgery alone claims ↑ in 5-yr SR with IORT.
Chen & Song 1994, China randomized stage 3 & 4 patients for surgery with IORT Vs
surgery alone claims ↑ in SR only in stage 3.
Sindelar & Tepper et al in 1993 , NCI (National Cancer institute) claims no survival
benefit with IORT, but improvement in local recurrence (44% Vs 92%, p < 0.001).
Still it needs to define the role of IORT in gastric carcinoma.

82. Robot assisted Surgery
Robot assisted surgery (RAS)
Advantages
• Provides articulated movement
• Eliminates physiologic tremor
• Steady camera platform allows more precise instrument
movement and dissections
Song J et al. Ann Surg 2009;249(6):927–32

83. PROGNOSTIC FEATURES
2 important factors influencing survival in
resectable gastric cancer:
 depth of cancer invasion
 presence or absence of regional LN
involvement
5yrs survival rate:
10% in USA
50% in Japan

86. Palliative therapy
Palliative surgery
- Intention
To relieve pain and suffering without increasing morbidity or mortality
- Numerous palliative procedures
• Gastro-enterostomy (enteric
bypass)
Palliation – infrequent
19% felt they benefited
Peri-operative mortality – high
….ReMine WH. World J Surg 1979;3:721-9
….Monson JR et al. Cancer 1991;68:1863-8
• Partial gastrectomy
• Total gastrectomy
59% felt improved their QOL
• Esophago-gastrectomy
• Jejunostomy - for nutritional supplementation
• acute refractory hemorrhage - Endoscopic techniques (laser argon ablation,
epinephrine injection) and arterial embolization
• GOO – endoscopic dilation and stent placement (short term), CT, bypass with
gastrojejunostomy

87. Palliative Chemotherapy
 CEF - Improve survival in patients with unresectable tumor
Adverse reactions are common, with up to 50% of patients having severe
neutropenia or GI complaints.
 Cetuximab – epidermal growth factor receptor (EGFR) inhibitor
 Trastuzumab (Herceptin) – human EGFR2 (HER2) antagonist
better median survival and overall response rate than CEF

91. Take home Points
1) 6 cm margin clearance of tumour is recommended.
2) D2 lymphadenectomy is essential.
3) Resection of greater & lesser omentum is necessary.
4) Splenopancreatectomy only on indicated cases.
5) For proximal lesion varying length of esophagus
should be excised.
6) Judicious decision should be taken for total,
proximal & distal gastrectomy.
7) All patient should receive chemoradiation.

92. Screening
• Mostly barium studies, EGD is concerning findings
• Some use serum pepsinogen testing for high risk with EGD
confirmation
• H. pylori: sensitivity 88%, specificity 41%(Japan)
• 5-year survival 74-80 in screened group, 46-56% fornon-
screened group.

93. 53 YEAR OLD MALE
PRESENTS WITH C/O WORSENING NAUSEA VOMITING SINCE 1 MONTHS
3-4 EPISODES PER DAY NON PROJECTILE
EPIGASTRIC BURNING+
NO C/O LOOSE STOOLS/CONSTIPATION /MALENA
C/O WEIGHT LOSS 8 KG IN LAST 2 MONTHs
LABS-
CBC-
HB-16.5 TLC-12.41 NEUTROPHIL -9.58, PLATELETS-310
ESR-9
CRP-2.81
S.CREATININE-1.96
S.ALBUMIN-4.90
TOTAL BILIRUBIN-0.7
S.AMYLASE , S.LIPASE- NORMAL
CEA-3.33
CA 19.9- 449.10
BLOOD GROUP-AB Negative
CASE CAPSULE

94. HRCT
Multifocal patchy peri-bronchovascular mild ground glass densities in right lung lower lobe
and middle lobe, possible due to aspiration. Alternatively, it could be due to infective
aetiology. CO-RADS 3 observation.
X RAY Abdomen AP Erect
No dilated bowel loops, or obstructive air-fluid levels are seen. No free air is seen under
the domes of diaphragm. No radio-opaque calculus is seen in the abdomen. The visualized
bones are unremarkable

95. CT Abdomen pelvis reveals features of gastric outlet obstruction secondary to an annular lumen constrictive
ulceroproliferative lesion in the antro-pylorus measuring 4.9 CM in length and 2.0 CM in maximum thickness.
Full thickness mural invasion is seen with subtle whiskering of the adjacent fat and loss of fat planes with the
ventrosuperior aspect of the pancreatic head.
No overt significantly enlarged regional adenopathy, with loss of fat planes with the ventrosuperior aspect of the
pancreatic head.
Recommend: Endoscopy and biopsy for histological confirmation

96. WB FDG PET CECT scan
Metabolically active enhancing transmural soft tissue thickening/lesion involving the antro-pyloric region of stomach
with gastric outlet obstruction .
Linear benign inflammatory lesion in the lower third of the esophagus. Benign lung lesions described above.
No suggestion of any other significant FDG concentrating active disease foci noted in the present whole body PET-CT
scan

97. Endoscopy done which s/o-
1. Esophageal ulcers
2. GERD LA Grade 1
3. Antropyloric area revealed ulceroproleferative lesion.
Biopsy taken to rule out
? Ca Stomach, ?Infiltrating pancreatic head malignancy

98. ENDOSCOPIC ANTROPYLORIC ULCEROPROLIFERATIVE LESION BIOPSY- POORLY
DIFFERENTITED ADENOCARCINOMA WITH SIGNET RING CELLS
MULTIDISIPLINARY TEAM INVOLVED AND ONCOLOGY OPINION TAKEN AND
DIAGNOSTIC LAPAROSCOPY AND FURTHER SURGERY WAS PLANNED.
Diagnostic Laparoscopy done and the entire abdomen inspected.
No evidence of any metastatic lesions in omentum or in the peritoneal site. Only
serosal involvement of tumor in the region of antrum and pylorus
Lap D2 Radical Total Gastrectomy Performed.
Chemoport insertion done to followed likely by adjuvant chemotherapy

99. Post operative care-
• Extubated and shifted to ICU
• Fluid and Electrolyte Management done
• TPN started
• Foleys removed on POD-1
• POD-2- shifted out to wards
• POD-3 Gastrograffin study done through Ryles tube
• There is smooth transit of the contrast across
• the distal oesophagus traversing anastomotic site
• into jejunal loops which appear mildly prominent.
• No extraluminal leak of contrast is evident.
14/06/21-
HPE-Path - Preliminary evalution shows a SIGNET RING CELL CARCINOMA with 3 possible
nodes involved
PATHOLOGICAL STAGGING- pT3pN2M0
IHC for Mismatch repair(MMR) s/o- MLH1 ,MSH 2,MSH 6 ,PMS 2 EXPRESSION +VE
POD-7
Drain removed
DISCHARGED ON POD-8