2. 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
3. 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
4. Early gastric cancer
Defined as a tumor confined to the mucosal or sub-mucosal layer,
with or without lymph node metastasis
5. Signs and Symptoms
Early 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%
7. Signs and Symptoms
Advanced 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%
8. 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
10. • 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:
11. 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
12. TNM STAGING
PRIMARY 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
13. T stage (UICC TNM 2002)
T4
T3
T2a
T1
Adjacent
structure
T2b
14. TNM STAGING
REGIONAL 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
17. 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 M0
T3 N0 M0
• Stage IIIA T2a/b N2 M0
T3 N1 M0
T4 N0 M0
• Stage IIIB T3 N2 M0
• Stage IV T4 N1-3 M0
T1-3 N3 M0
Any T Any N M1
18. 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)
19. • 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.
20. 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.
21. 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
25. Radiologic diagnosis
For reasons of cost and availability, radiography may
sometimes be the first diagnostic procedure performed
Classic 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
28. 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.
30. 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
31. 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
32. 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
39. 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
40. 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.
41. 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.
42. PALLIATIVE CHEMO THERAPY
• Median survival benefit 3 – 6 months
• Combination therapy superior
• 50% gain improvement in QOL
43. COMPLICATIONS OF
GASTRECTOMY
• LEAKAGE FROM ESOPHAGO JEJUNOSTOMY
• FISTULA FROM WOUND/DRAIN SITE
• LEAKAGE FROM DUODENAL STUMP
• PARA DUODENAL COLLECTIONS
• BILIARY PERITONITIS
• CATASTROPHIC SECONDARY HAEMORHAGE
44. LONG TERM COMPLICATIONS
• REDUCED CAPACITY
• DUMPING
• DIARRHOREA
• NUTRITIONAL DEFICIENCIES
• VITAMIN B12 DEFICIENCY
45. PREVENTION
Eradication 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
