for information purpose

1. PRESENTED BY :-
Dr. Nitin Alapure
(PG SCHOLAR)
GUIDE: DR APARNA RAUT
(HOD OF SHALYATANTRA DEPT
Carcinoma of Stomach

2. Anatomy

3. Parts of the stomach
The stomach has 5parts

4. • Cardia: The first portion of stomach (closest to the esophagus)
• Fundus: The upper part of the stomach next to the cardia.
• Body (corpus): The main part of the stomach, between
the upper and lower parts.
• Antrum: The lower portion (near the intestine), where
the food is mixed with gastric juice.
• Pylorus : The last part of the stomach, which acts
• as a valve to control emptying of the stomach
• contents into the small intestine.

5. Thefirst 3 parts of the stomach (cardia, fundus, and body) are
sometimes called the proximal stomach.
Somecells in these parts of the stomach make acid and pepsin (a
digestive enzyme), the parts of the gastric juice that help digest food.
Theyalso make a protein called intrinsic factor, which the body needs
to absorb vitamin B12.
The lower 2 parts (antrum and pylorus) are called the distal stomach.
The stomach has 2 curves, which form its inner and outer
borders. They are called the lesser curvature and greater
curvature, respectively.

6. Blood supply
Most of the blood supply to the stomach is from
Four main arteries:
1. Right Gastric Artery (branch of common hepatic artery)
2. Left Gastric Artery (Branch of celiac artery)
3. Right Gastro-omental Artery (Branch of gastroduodenal artery)
4. Left Gastro-omental Artery and Short gastric Artery

7. Venous drainage:-
Venous drainage parallels the arterial supply
1. Left and right gastric veins drain into the portal vein
2. Right Gastro-omental drains into the SMV
3. Left Gastro-omental drains into the splenic vein

8. Lymphatic drainage is into four zones:
1. Superior gastric
2. Suprapyloric
3. Pancreaticolienal
4. Inferior gastric/subpyloric
Allfour drain into the
celiac group of nodes
and into the thoracic duct.
Gastric cancers drain into
any of these groups

9. In- nervation:
The stomach receives innervation from the autonomic nervous system
Parasympathetic nerve supply
Sympathetic nerve supply arises from the T6-T9 spinal cord
segments
Parasympathetic via the vagus.

10. Histology
Stomach has five layers:
1. Mucosa
2. Sub-mucosa
3. Muscularis propria
4. Sub serosa
5. Serosa
The layers are important in determining the stage (extent) of the cancer and
in helping to determine a person’s prognosis (outlook).
Asa cancer grows from the mucosa into deeper layers, the stage becomes
more advanced and the prognosis is not as good.

11. Gastric Carcinoma:
• A malignant tumor of the stomach or Ulcer in stomtch.
• Males are more 3 more prone than female.
• Occures at any age but most common in 5th decade.
• Common in all gastric disorders.
Etiology Factor:-
• Spicy food
• Hot climate
• Irritating Substances like tobacco , gutkha, pan masala etc.
• Strong chemical consumption like Alcohol , Sprite , kerosene , narcotic drugs
• Vegetable's which highly used pesticides.
• Eating junk food tied to higher risk of numerous cancers.

12. Predisposing :
• Pernicious anemia (vitamin B-12 deficiency anemias -inability to absorb the vitamin B-12)
• Gastritis
• Previous gastric resection.
• Chronic peptic ulcer (give rise to 1%)
• Smoking.
• Alcohol.
Environmental:
• H.pylori infection Sero(+)patients have 6-9 folds risk
• low socioeconomic Status
• Nationality (JAPAN)
• Hot climate
Genetic:
• Blood group A
• HNPCC: Hereditary non- polyposis colon cancer.

13. Clinical Features
Most of patients present with advanced stage because there are no early specific signs and
symptoms. Time lag between onset of disease and onset of symptoms.
1. Indigestion (Malabsorption Syndrome)
Malabsorption syndrome refers to a number of disorders in which the
small intestine can't absorb enough of certain nutrients and fluids.
2. Asthenia
• abnormal physical weakness or lack of energy.
• septic absorption from the tumor
3. Dysphagia
4. Anorexia
5. Vomiting
6. Malena
7. Hematemesis
8. Loss of Weight

14. 9. Left Supra Clavicular lymph nodes enlarged :-
Metastatic spread of cancer via the thoracic duct may lead to an enlargement of the left
supraclavicular node, known as the Virchow node (VN)
Vichows Node may be present in abdomen infection , particularly gastric cancer, ovarian
cancer, testicular cancer and kidney cancer.

15. Virchow's lymph node

16. 10. Sister mary joseph node:-
A palpable nodule bulging into the umbilicus as a result of metastasis of a
malignant cancer in the Stomach , pelvis or abdomen.

17. • Specific symptoms depending on the site of tumor.
• Tumor in pyloric region may present with gastric outlet obstruction.
• Tumor in proximal region may present with dysphagia , hematemesis .
• From the body of stomach may present as only mass per abdomen(silent
variety).

18. TNM Classification of stomach Cancer
Tumour (T) - T describes the size of the tumour.
There are 4 main stages of tumour size in stomach cancer.
• T1 means the tumour has started to grow into the wall of the stomach.
It’s divided into T1a and T1b:
T1a means the tumour is within the inner layers of the stomach
(the mucosa)
T1b means the tumour has grown through the mucosa and into
a layer of supportive tissue called the submucosa
• T2 means the tumour has grown into the muscle layer of the stomach
• T3 means the tumour has grown into the outer lining of the stomach
• T4 means that the tumor has grown through the outer lining of the stomach. It’s divided into T4a and b
T4a means the tumour has broken through the outer lining of the stomach wall
T4b means the tumour has grown through the stomach wall and into other organs or body
structures nearby such as the liver, food pipe (esophagus) or abdominal wall

19. Node (N)
Node (N) describes whether the cancer has spread to the lymph nodes
There are 4 possible stages describing lymph nodes – N0, N1, N2 and N3:
• N0 means there are no lymph nodes containing cancer cells.
• N1 means there are cancer cells in 1 to 2 lymph nodes near to the stomach.
• N2 means there are cancer cells in 3 to 6 nearby lymph nodes.
• N3 is split into N3a and N3b:
N3a means there are cancer cells in 7 to 15 nearby lymph nodes
N3b means there are cancer cells in 16 or more nearby lymph nodes

20. Metastasis (M)
Metastasis describes whether the cancer has spread to a different part of the body.
There are 2 stages of metastasis:
• M0 means the cancer has not spread to other organs
• M1 means the cancer has spread to other parts of the body

22. Spread of Gastric Cancer:-
• Direct Spread
Tumor penetrates the muscularis, serosa & Adjacent organs
(Pancreas , colon &liver)
• Lymphatic spread
What is important here is Virchow’s node
• Blood-borne metastasis
Usually with extensive Disease where liver 1st Involved then lung & Bone
• Transperitoneal spread
This is common Anywhere in peritoneal cavity (Ascites)
Krukenberg tumor (ovaries) Sister Joseph nodule (umbilicus)

23. INVESTIGATIONS
• CBC
• LFT
• RFT,
• Stool examination for occult blood,
• CXR.
• Serum tumour markers:- (CA72-4 , CEA , CA19-9)
Monoclonal antibodies are used to detect serum antigens associated
with specific malignancies. These tumor markers are most useful for
monitoring response to therapy and detecting early relapse.
• Specific:-
 UGI endoscopy with biopsy,
 CT, MRI & USG
 Laparoscopy

24. Upper gastro intestinal endoscopy.
Diagnostic accuracy is 98% if upto 7 biopsies is taken.
You may see an
• ulcer
• polypoid mass
• superficial spreading

25. Biopsy :-
taking a small piece of tissue from the stomach to look at under
a microscope for signs of cancer cells. It might done during an
endoscopy.

26. IF YOU SEE ULCER BENIGN OR MALIGNANT?
BENIGN MALIGNANT
Round to oval punched out lesion with
straight walls & flat smooth base
Irregular outline with necrotic or
hemorrhagic base
Smooth margins with normal
surrounding mucosa
Irregular & raised margins
Majority<2cm Any size
Mostly on lesser curvature Anywhere

27. Management
• Surgery
• Chemotherapy
• Radiotherapy
Prognosis of carcinoma is discouraging .patient could survive for 2-3 year with
carcinoma of stomach but surgical procedure ,radiotherapy and chemo-
therapy give better result for 5year
Complete restoration of health after surgical treatment is impossible due to
most common complication Mal-absorption syndrome

28. Gastrectomy
surgical removal of a part or the whole of the stomach
• Total gastrectomy
Indicated when the extent, or location, of the primary tumour is such that adequate
margins of resection (i.e. 4–6 cm) are not possible by a subtotal gastrectomy. proximal gastric
tumours and extensive lesions.
• Subtotal gastrectomy
particularly suitable for small gastric tumours
involving the pylorus and distal third of the stomach.

29. Total gastrectomy

30. Post-Operative Complications
1.Leakage from
duodenal stump.
2.Secondary
hemorrhage.
3.Nutritional
deficiency in long
term.

31. 2.Chemotherapy:
• Responds well, but there is no effect on servival.
• Epirubicin, cisplatin & 5-flurouracil (3 wks) 6 cycles
• Response rate : 40% .
3. Radiotherapy:
• Postoperative - radiotherapy: may decrease the recurrence.
high doses of radiation to kill cancer cells and shrink tumors. At low
doses, radiation is used in x-rays

32. What are the side-effects of radio therapy and chemotherapy
• fatigue (tiredness)
• dry, red or itchy skin.
• loss of appetite.
• nausea (feeling sick)
• digestive problems.
• Hair loss.
• dry or sore throat or mouth.
• cough or shortness of breath.

33. Duodenal cancer
Duodenal cancer is a cancer in the first section of the small intestine known as the duodenum.
Cancer of the duodenum is relatively rare compared to stomach cancer and colorectal cancer.
Its histology is usually adenocarcinoma

34. • The duodenum is the first part of the small intestine.
• It is located between the stomach and the jejunum.
• After foods combine with stomach acid, they descend
into the duodenum where they mix with bile from
the gallbladder and digestive fluid from the pancreas.

35. Signs and symptoms :-
• The cancerous mass tends to block food from
getting to the small intestine.
• If food cannot get to the intestines, it will cause
pain, acid reflux, and weight loss because the food
cannot get to where it is supposed to be processed
and absorbed by the body.
• abdominal pain,
• weight loss,
• nausea,
• vomiting,
• chronic gastrointestinal bleeding

36. Treatment
Resection is sometimes a part of a treatment plan,but duodenal cancer is difficult to remove surgically
because of the area that it resides in—there are many blood vessels supplying the lower body.
Chemotherapy is sometimes used to try to shrink the cancerous mass. Other times intestinal bypass
surgery is tried to reroute the stomach to intestine connection around the blockage
Gastric bypass surgery:-

37. Gastro jejunostomy:-

38. Blood Group - Disease Associated with blood group
A - Stomach Cancer
A,AB,B - Pancreatic cancer
O - duodenal ulcer