1. Stomach Cancer
Dr. Arifa Malek PGY3
Dr. Mohamed Saleh PGY1
2.
3. A 66Y/O AA Male With PMH of HTN,
Dyslipidemia, Hypothyroidism presented in PCP
office with C/O Dysphagia particularly with solids
since July 2012.
WT Loss of 10-15 Lbs in 5 month Period.
Decreased oral intake for 1 month , Dysphagia
getting Worse progressively.
5. PT was seen in FMC in June 2012 with
Epigastric pain, CT Abdomen and basic Lab work
was done Results WNL.
F/U in Oct 2012 initially Barium Swallow study
was odered and later EGD by Dr.Ferguson in Nov
2012.
Further workup and Treatment in Progress.
6.
7. Final Diagnosis :
A-Stomach Cardia Biopsy: Adenocarcinoma
Moderately Differentiated (intestinal type by Lauren
classification ). (special stain negative for Helicobacter
pylori).
B- Esophageal Biopsy:
1-Minute fragment of Adenocarcinoma.
2-Additional Gastric glands with no Histologic
Abnormalities.
10. •The overall incidence of gastric cancer in the
United States has rapidly declined over the
past 50 years.
•Gastric cancer is now 13th most common
cause of cancer mortality in the United
States.
•Estimated new cases and deaths from
stomach cancer in the United States in 2012:
New cases: 21,320
Deaths: 10,540
11. In developing countries, the incidence of gastric
cancer is much higher and is second only to lung
cancer in rates of mortality
The typical patient with gastric cancer is male
(male-to-female ratio, 1.7:1) and between 40 and
70 years of age (mean age, 65 years). Native
Americans, Hispanic Americans, and Afro-
Americans are twice as likely as Caucasian to
have gastric carcinoma.
12.
13. The overall declining incidence of gastric
carcinoma is related to distal stomach tumors
caused by Helicobacter pylori infection. Proximal
stomach tumors of the cardiac region have
actually increased in incidence in recent years.
This trend has been attributed to the increased
incidence of Barrett’s esophagus and its direct
correlation with the development of esophageal
adenocarcinoma
14. Ninety-five
percent of all malignant
gastric tumors are
adenocarcinomas.
The remaining 5 percent include
lymphomas, sarcomas, which
involve the connective tissue (such
as muscle, fat, or blood vessels)
15. Many risk factors have been
associated with the development
of gastric cancer, and the
pathogenesis is most likely
multifactorial.
21. These risk factors are most
commonly related to the development
of adenocarcinoma.
Etiologies other than Helicobacter
pylori infection or chronic gastritis
have been difficult to elucidate for
mucosa-associated lymphoid tissue
tumor.
22.
23.
24. The presenting symptoms of early gastric cancer
are nonspecific. Patients may be
1-Asymptomatic
2-Dyspepsia
3- mild epigastric pain,
4- nausea, or anorexia.
Given the high prevalence of dyspepsia in the
general population, many EGCs may be
diagnosed incidentally.
25. The nonspecific nature of symptoms in EGC
complicates optimal disease management
strategies for patients presenting with dyspepsia.
While the prevalence of gastric carcinoma among
patients presenting with dyspepsia is low in the
United States
There are no reliable clinical or laboratory features
to distinguish patients with benign causes of
dyspepsia from those with more serious
underlying disease.
26. Warning (or alarm) symptoms suggestive of
invasive disease in patients with EGC :
1- Anemia 5-15 %
2- Weight loss 4 to 40 %
By comparison, weight loss occurs in more than
60 percent of those with advanced gastric
adenocarcinoma
29. 1- A palpably enlarged stomach,
2- primary mass (rare),
3- An enlarged liver
4-Virchow’s node
5-Sister Mary Joseph’s nodule
6- Blumer’s shelf (metastatic tumor felt on
rectal examination, with growth in the
rectouterine/rectovesical space).
30.
31. Assists in determining optimal therapy.
CBC identifies anemia ,with maybe caused by
bleeding ,liver dysfunction, or poor nutrition.
15-20% have anemia .
Tumor markers :
1-CEA :carcino-embryonic antigen
2-CA19-9:carbohydrte Antigen
3-CA724: carbohydrate Antigen
32. 1-
Double-contrast barium swallow, a cost-
conscious, noninvasive, and readily
available study, may be the initial step.
2-Esophagogastroduodenoscopy (EGD) is
the diagnostic imaging procedure of choice
in the work-up of gastric carcinoma.
33.
34.
35.
36.
37.
38.
39. EGD is a highly sensitive and
specific diagnostic test, especially
when combined with endoscopic
biopsy. Multiple biopsy specimens
should be obtained from any visually
suspicious areas; this step involves
repeated sampling at the same
tissue site, so that each subsequent
biopsy reaches deeper into the
gastric wall.
40.
41. After the initial diagnosis of gastric cancer is
established, further evaluation for metastases is
necessary to determine treatment options.
1- Computed tomographic (CT) scanning is a
useful method of detecting liver metastases
greater than 5 mm in diameter, perigastric
involvement, peritoneal seeding, and
involvement of other peritoneal structures (e.g.,
ovaries, rectal shelf).
42. CT scanning is unable to allow assessment
of tumor spread to adjacent lymph nodes
unless they are enlarged. In addition, it has
not been shown to be effective in allowing
determination of the depth of tumor invasion
and cannot reliably support detection of
solitary liver or lung metastases smaller than
5 mm in diameter.
43. Endoscopic ultrasonography (EUS) is
a modality that allows for more
accurate staging. In EUS, the
transducer is placed directly next to
the gastric wall, and high-frequency
sound waves are used to determine
the depth of tumor invasion and
detect local lymph node involvement,
which may be assessed by operative
biopsy.
44.
45. As with all types of cancer, the most
important indicator of resectability and
prognosis for gastric cancer is the
clinicopathologic stage.
There are several similar staging
classifications, but in the United States, the
most commonly used system is the American
Joint Committee on Cancer TNM (tumor,
node, metastasis) staging system .
46. Thetwo most important factors influencing
survival in patients with resectable gastric
cancer are
1- Depth of cancer invasion through the
gastric wall
2- Number of lymph nodes involved.
47. 1- Primary tumor (T)
T0: No evidence of primary tumor
Tis: Carcinoma in situ: intraepithelial tumor without
invasion of the lamina propria
T1: Tumor invades lamina propria or submucosa
T2: Tumor invades the muscularis propria or the
subserosa*
T3: Tumor penetrates the serosa (visceral
peritoneum) without invading adjacent structures.
T4: Tumor invades adjacent structures.
48.
49. N0: No regional lymph node metastasis
N1: Metastasis in 1 to 6 regional lymph
nodes
N2: Metastasis in 7 to 15 regional lymph
nodes
N3: Metastasis in more than 15 regional
lymph nodes
50. M0: No distant metastasis
M1: Distant metastasis
55. Surgery is a common treatment of all stages of gastric
cancer. The following types of surgery may be used:
Subtotal gastrectomy: nearby lymph nodes , and
parts of other tissues and organs near the tumor. The
spleen may be removed.
Total gastrectomy: Removal of the entire stomach,
nearby lymph nodes, and parts of the esophagus,
small intestine, and other tissues near the tumor. The
spleen may be removed.
56.
57. Chemotherapy drugs commonly used to
treat stomach cancer include:
1. cisplatin
2. epirubicin
3. and fluorouracil (also called 5FU).
Thesedrugs may be given together as the
ECF regimen.
58. It may be used before surgery to reduce the size
of the tumor , or after surgery to reduce the risk of
cancer coming back after surgery.
It may also be used to try to slow down the cancer
and improve quality of life if an operation to
remove the cancer isn’t possible.
Chemotherapy is often a successful treatment for
stomach cancer.
However, it doesn’t always shrink the cancer and
may cause side effects without giving much
benefit.
59. Radiation therapy is a cancer treatment that
uses high-energy x-rays or other types of
radiation .
There are two types of radiation therapy.
External radiation therapy and Internal
radiation therapy uses a radioactive substance
sealed in needles, seeds , wires, or catheters
that are placed directly into or near the cancer.
60. studies have shown that patients receiving
combined chemoradiation therapy have
demonstrated improved disease-free survival and
improved overall survival rates.
In one series,29 patients were randomized to
receive postoperative radiotherapy and 5-
fluorouracil chemotherapy or surgery alone.
Results of this study demonstrated improved
survival in the patients receiving adjuvant therapy
compared with those who received surgery alone
(52 percent three-year survival versus 41 percent,
respectively).
.
61. Targeted therapy is a type of treatment that
uses drugs or other substances to identify and
attack specific cancer cells without harming
normal cells.
Monoclonal antibody therapy is a type of
targeted therapy used in the treatment of
gastric cancer.
62. These antibodies can identify
substances on cancer cells or normal
substances that may help cancer
cells grow. The antibodies attach to
the substances and kill the cancer
cells, block their growth, or keep them
from spreading
63. A recombinant humanized monoclonal antibody
directed against the human epidermal growth
factor receptor 2 (HER2). After binding to HER2
on the tumor cell surface, trastuzumab induces an
antibody-dependent cell-mediated cytotoxicity
against tumor cells that overexpress HER2. HER2
is over expressed by many adenocarcinomas,
particularly gastric and breast adenocarcinomas
64. Many patients present with distant metastases or
direct invasion of organs, obviating the possibility
of complete resection. In the palliative setting,
radiotherapy may provide relief from bleeding,
obstruction, and pain in patients with advanced
disease, although the duration of palliation is short
(mean, six to 18 months). Surgical procedures
such as wide local excision, partial gastrectomy,
total gastrectomy, or gastrointestinal bypass also
are performed with palliative intent, to allow oral
intake of food and alleviate pain.
65.
66. The value of screening asymptomatic individuals for
gastric cancer remains controversial
Mass screening programs have been implemented in
some countries (eg, Japan, Venezuela, and Chile)
where there continues to be a high incidence of gastric
cancer By contrast, the relatively low incidence of
gastric cancer in other regions (including the United
States) makes this strategy costly and unwarranted.
In low risk regions case-finding rather than mass
screening is the most appropriate approach for early
detection.
67. Screening methods and intervals vary in different
settings.
Population screening for gastric cancer in Japan,
for example, is recommended for individuals older
than 40 years.
In contrast, gastric cancer screening every two
years via either upper gastrointestinal series or
upper endoscopy has been recommended in
Korea for individuals aged 40 years and older.
68. Screening has traditionally involved a simple Risk
interview and barium studies.
The barium studies include the conventional
double contrast barium x-ray with
photofluorography or
The new double contrast barium x-ray with digital
radiography.
An upper endoscopy is performed if any
abnormality is detected
69. The new guidelines by the American College of Physicians (ACP)
recommend against screening the general population with GERD
this way, partly because the cancer is rare even in this at-risk
group.
Although the ACP guidelines are similar to those of organizations
such as the American Gastroenterological Association, they stand
apart for specifically recommending against screening women with
GERD for esophageal cancer.
The ACP guidelines do recommend screening men over 50 who
have had GERD for more than five years and who have other risk
factors for esophageal cancer, including smoking and being
overweight, because this group faces elevated esophageal cancer
risk.
70. The guidelines, based on a review of current research
on GERD and the use of endoscopy, were published
Dec. 4 in the Annals of Internal Medicine.
The guidelines point to two other groups that should
receive an upper endoscopy. One is people who
experience GERD along with symptoms including
vomiting and difficulty swallowing, which can be signs
of treatable conditions, such as narrowing of the
esophagus.
Upper endoscopy is also recommended for those who
continue to have heartburn despite medications.
71. Primary prevention with H. pylori eradication — The
recognition of H. pylori as a gastric carcinogen has
provided the opportunity to institute strategies aimed at
primary prevention through its eradication. Emerging
data point toward the effectiveness of such
approaches .
Some of the most direct evidence was provided in a
controlled trial from China in which 1630 healthy
carriers of H. pylori infection were randomly assigned to
H. pylori eradication or placebo precancerous lesions at
baseline.
72. Routine screening for gastric cancer is not recommended outside of a
few countries with a high gastric cancer burden that have already
implemented screening programs. The effectiveness of these programs
is unclear.
Eradication of H. pylori has the potential to reduce the burden of gastric
cancer, Large scale studies are urgently needed to clarify the targeted
population and cost effectiveness of mass screening of H. pylori and the
subsequent eradication strategy in different populations with different
gastric cancer incidences.
In populations with a low gastric cancer burden, the decision to
recommend a screening program should be made on an individual
patient basis. Periodic upper endoscopy (possibly with specialized
techniques such as chromoendoscopy or magnification endoscopy) can
be offered to patients who are considered to be at increased risk ,
although the benefits and risks of such an approach are unclear.
