GASTRIC CANCER

Done by Eman,Jumana,Dania

The wall of the stomach has five layers:

Inner layer or lining (mucosa): Most stomach cancers
begin in this layer.
Submucosa: This is the support tissue for the inner layer.
Muscle layer: Muscles in this layer contract to mix and mash
the food.
Subserosa: This is the support tissue for the outer layer.
Outer layer (serosa): The outer layer covers the stomach. It
holds the stomach in place.

Blood Supply

venous drainage

Lymphatic drainage of the stomach

Antrum to right gastric LN superiorly, and right

.gastroepiploic and subpyloric LN inferiorly
Pylorus to right gastric suprapyloric nodes
superiorly and subpyloric LN around the
.gastroduodenal artery inferiorly
efferent lymphatics from suprapyloric lymph
nodes converge on the para-aortic nodes around
the coeliac axis, whereas the efferent lymphatics
from the subpyloric lymph nodes pass up to the
main superior mesenteric lymph nodes around
. the origin of the superior mesenteric artery
Lymphatic vessels related to the cardiac orifice of

Carcinoma of the stomach is a major cause of

cancer mortality
Worldwide
Gastric cancer is actually an eminently curable
disease provided that it is detected at an
appropriate stage and treated adequately
Rarely disseminates widely before it has involved
the lymph nodes and, therefore, there is an
opportunity to cure the disease prior to
dissemination
.Early diagnosis is therefore the key to success
The only treatment modality able to cure the
.disease is resection surgery

Gastric CA Epidemiology
1.
2.

3.
4.
5.
6.
7.

8.

Incidence
There are marked variations in the incidence of gastric
cancer worldwide.
In the UK the incidence is approximately 15 cases per
100 000 population per year,
in the USA 10 cases per 100 000
and in Eastern Europe 40 cases per 100 000
In Japan the disease is much more common, with an
incidence of approximately 70 cases per
100 000 population per year, and there are small
geographical areas in China where the incidence is
double that in Japan.

10

Gastric cancer is one of the most common

cancers worldwide
Gastric cancer is the second most common
cause of cancer-related death in the world,
and it remains difficult to cure in Western
countries , because most patients present
with advanced disease
Declined rapidly over the recent few
decades
Highest in Eastern Asia, Eastern Europe,
and South America, while the lowest rates
are in North America and parts of Africa

Etiology

Gastric cancer is a multifactorial disease

H. pylori
Helicobacter seems to be principally
associated with carcinoma of the body and
distal stomach rather than the proximal
stomach.
As Helicobacter is associated with gastritis,
gastric atrophy and intestinal metaplasia,
the association with malignancies perhaps
not surprising

RISK FACTORS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

Gender : M>F
Age
Class
Environmental factors
Diet & Smoking
H.pylori & chronic gastritis
Adenomatous polyp
Previous gastric surgery : Billroth 1 & 2
Pernicious anemia
Menetriers disease
Familial gastric cancer
Blood group A
Hypogammaglobulinemia

Pathology

The most useful classification of gastric cancer is the

Lauren classification. In this system there are principally
two forms of gastric cancer: intestinal and diffuse.
In Intestinal gastric cancer, the tumour resembles a
carcinoma elsewhere in the tubular gastrointestinal
tract and forms polypoid tumours or ulcers. It probably
arises in areas of intestinal metaplasia.
In contrast, Diffuse gastric cancer infiltrates deeply into
the stomach without forming obvious mass lesions, but
spreads widely in the gastric wall. Not surprisingly, this
has a much worse prognosis.
A small proportion of gastric cancers are of mixed
morphology.

Macroscopic
Types

Incidence
Site
Gross
Different

14

Proliferative

Ulcerative

Infiltrating

% 40

% 40

% 20

Body & fundus

pylorus or lesser
curvature
Malignant ulcer

involve stomach
diffusely
infiltrates all layers

moderately

poorly

cauliflower
mass
well

Microscopic
Adenocarcinoma

Columnar cell
adenocarcinoma
Intestinal
type

15

Colloid or mucoid
adenocarcinoma
Diffuse
type

Squamous cell
carcinoma

INTESTINAL
GASTRIC CA
DIFFUSE GASTRIC
CA

Gastric cancer can be divided into early gastric

cancer and advanced gastric cancer. Early gastric
cancer is defined as cancer limited to the mucosa
and submucosa with or without lymph node
involvement (T1, any N).
This can be either protruding, superficial or
excavated in the Japanese classification. This type
of cancer is eminently curable, and even early
gastric cancers associated with lymph node
involvement have five-year survival rates in the
region of 90 per cent.

Site

The proximal stomach is now the most common

site for gastric cancer in the West. Because so
many malignancies occur at the
oesophagogastric junction, and because the
lower oesophagus is also a very common site of
adenocarcinoma, it is artificial to separate the
stomach from the oesophagus.
This high prevalence of proximal gastric cancer is
not seen in Japan, where distal cancer still
predominates, as it does in most of the rest of
the world.

Spread of Gastric Cancer

Distant metastases are uncommon in the
.absence of lymph node metastases
The intestinal and diffuse types of
gastric cancer spread differently. The
diffuse type spreads via the submucosal
and subserosal lymphatic plexus and it
penetrates the gastric wall at an early
.stage

Direct spread
penetrates the muscularis, serosa and
ultimately adjacent organs
Lymphatic spread
by both permeation and emboli to the
affected tiers of nodes. This may be
extensive, the tumour even appearing in
the supraclavicular nodes (Troisiers
sign).

Blood-borne metastases
first to the liver , subsequently to other organs eg;
lung and bone.
Transperitoneal spread
common once the tumour has reached the serosa
indicates incurability. commonly give rise to
ascites. tumour shelf.
Krukenbergs tumours
Sister Josephs nodule
Detected most effectively by laparoscopy and
cytology

Gastric CA - Clinically
In the United States, about 25% of stomach cancer
patients present with localized disease, 31% present with
regional disease, and 32% present with distant metastatic
disease

NOTE : Gastric CA in
cardia gives dysphagia.
pylorus gives vomiting.

22

.Gastric CA Cont

23

Early symptoms:

Weight loss

Abdominal pain (epigastric, vague and mild early in the

disease but more severe and constant as the disease
progresses)

Nausea/Vomiting/Hematemesis

Dysphagia (In proximal stomach or at the esophagogastric

junction)

Melena

Early satiety

Postprandial fullness

Anorexia

Dyspepsia

.Gastric CA Cont

Late symptoms: (Due to extension)

24

Abdominal distention (Ascites)

Pleural effusions
Obstruction of the gastric outlet,
gastroesophageal junction, or small bowel
Bleeding in the stomach from esophageal
varices
Jaundice
Headache

.Gastric CA Cont

Signs: (Indicate late disease)

25

Weight loss
Ascites
Hepatomegaly
Sister Mary Joseph nodule
Virchow nodes
Irish node
Blumer shelf
Anemia
Paraneoplastic syndromes such as dermatomyositis,
acanthosis nigricans, microangiopathic hemolytic anemia,
membranous nephropathy, and hypercoagulable state

Investigation of Gastric CA
26

CBC anemia

Stool for occult blood

LFT liver mets

Electrolyte

Tumor markers such as CEA and CA 19-9: Elevated CEA in 45-50% of

cases; elevated CA 19-9 in about 20% of cases

1- for diagnosis :
A-Upper GI endoscope Gold standard for Dx
B-barim meal (accuracy 75% ) :
lf cauliflower mass will be as irregular filling defect
lf malignant ulcer Ulcer niche >2cms (small depression in hollow
organ )

Linitis plastica of the stomach as seen

on upper gastrointestinal (UGI) series

Upper gastrointestinal study reveals

fixed narrowing of the entire proximal
stomach (arrows) due to submucosal
.invasion by a gastric cancer
27

Normal upper GI series

Normal air-contrast upper

gastrointestinal study showing
normal gastric folds and small
intestinal anatomy, and no
.masses

Endoscopy

Ultrasonography
Mostly use for
proximal tumor

CT

CT/PET

Laparoscopy

Investigation of Gastric CA
33

2-For staging :
Abdominal U/S
Abdominal CT
Laproscopy to detect peritoneal seeding
For follow up :

Tumor marker : CEA increase in 65%and indicates

extensive spread . lt is of prognostic value rather
than diagnostic

CA 19-9

CA72-4 (more recent and more specific)

For preop preparations : CBC ,KFT ,LFT
,Electrolyte

TNM Staging
International Union Against Cancer (UICC)
.staging of gastric cancer
T Stage
Tis, carcinoma in situ_
T1, tumour in mucosa or submucosa
T2, tumour into/through muscularis propria
T3, tumour through serosa
T4, tumour invading other structures

N Stage (requires at least 15 nodes to be

examined)
N0 No lymph nodes
N1 Metastasis in 12 regional nodes
N2 Metastasis in 36 regional nodes
N3a Metastasis in 715 regional nodes
N3b Metastasis in more than 15 regional nodes
M Stage
M0, no distant metastases
M1, distant metastases
(this includes peritoneum and distant lymph nodes )

STAGING
T1 N0 M0
T1 N1 M0
T2 N0 M0

IA
IB

T1 N2 M0
T2 N1 M0
T3 N0 M0

IIA

T1 N3 M0
T2 N2 M0
T3 N1 M0
T4a N0 M0

IIB

T2 N3 M0
T3 N2 M0
T4a N1 M0

IIIA

T3 N3 M0
T4a N2 M0
T4b N01 M0

IIIB

T4a N3 M0
T4b N23 M0

IIIC

Any T Any N M

IV

General treatment recommendations

:Treatment based on the following**
.Stage of disease
. Surgical fitness of patient
.The patients preference
Patient comorbidities

Operability
Endoscopic mucosal resection (IA)
Total gastrectomy
Subtotal gastrectomy
Palliative surgery ( In non curable cases)
One of the commoner indications for palliative surgery is gastric
outlet obstruction from stenosing distal gastric cancer and even
in this situation the use of expandable metal mesh stents can
offer better palliation in a significant
proportion . Other
indications is bleeding

Total gastrectomy
40

Subtotal gastrectomy
41

Complications of gastric
surgery
1.

Early complication :

1-Potential complications include the usual cardiac,

respiratory and wound complications that may occur
in any patient undergoing abdominal surgery.
2-risk of anastomotic leakage.
3-Fluid collections or abscesses are common,
particularly if extensive lymph node dissection has
been performed.
4-Afferent loop obstruction is due to a poorly
constructed afferent loop and this will lead to postprandial pain and nausea relived by vomiting.

:Late complication. 2
Late complications are due to changes in the anatomy and the
physiology of the upper gastrointestinal tract.
The complications include reflux gastritis and/or esophagitis,
dumping syndromes, diarrhea and nutritional deficiencies.
Most of the problems are most marked in the few months after
surgery and most fade within about one year.
*** Dumping refers to an array of gastrointestinal and vasomotor
symptoms attributed to rapid gastric emptying. The symptoms
include fullness, abdominal pain, nausea, vomiting and diarrhea.
The vasomotor symptoms are due to rapid fluid shifts into the
bowel lumen, and are the typical symptoms of hypovolemia. Late
dumping is due to an insulin surge soon after a meal, followed by
reactive hypoglycemia. The treatment of dumping is dietary.
Patients should eat small frequent meals, try to separate dry foods
from liquids, and avoid simple sugars. The severity of symptoms
settles with time.

Other treatment modalities

Because of the failure of radical surgery to cure

advanced gastric cancer, there has been interest in
.the use of radiotherapy and chemotherapy

Radiotherapy
The routine use of radiotherapy is controversial as the
results of clinical trials are inconclusive. There are a
number of radiosensitive tissues in the region of the
gastric bed, which limits the dose that can be given.
Radiotherapy has a role in the palliative treatment of
.painful bony metastases

Chemotherapy
Gastric cancer may respond well to combination
cytotoxic chemotherapy and neoadjuvant
chemotherapy improves the outcome following
surgery. Therefore, most patients should have
. chemotherapy before surgery
.Chemotherapy for advanced disease is palliative

GIST

Previously named leiomyoma and leiomyosarcoma

They are tumors of mesenchymal origin.
observed equally in males and females.
The tumors are associated with a mutation in the
tyrosine kinase c-kit oncogene.
GIST comprise 13 % of all gastrointestinal neoplasia.
The biological behavior of these tumors is
unpredictable but size and mitotic index are the best
predictors of metastasis.
Peritoneal and liver metastases are most common.
LN METS IS RARE

:Symptoms
they are noticed incidentally at endoscopy
Or it leading to bleeding if the mucosa
overlying the tumor ulcerates
. Non specific symptoms if large in size
:Diagnosis
Because the mucosa overlying the tumor is
normal, endoscopic biopsy can be
uninformative unless the tumor has ulcerated.
Targeted biopsy by endoscopic ultrasound is
. more helpful

Computed tomography of
the upper abdomen showing
a 3.5 cm gastrointestinal
stromal tumour arising from
.the gastric wall

treatment
surgery is the primary mode of treatment. Smaller
tumors can be treated by wedge excision although the
incidence of the condition is unclear
Larger tumors may require a gastrectomy or
duodenectomy but lymphadenectomy is not required.
Larger tumors which require multivisceral resection
may be better treated with three to six months of
imatinib prior to operation as this will usually radically
reduce the size and vascularity of the tumors.
Adjuvant imatinib for large resected tumors of high
malignant potential should probably be continued
indefinitely.

The prognosis of advanced metastatic

GIST has been dramatically improved with
imatinib chemotherapy but resection of
metastases, especially from the liver, still
.has an important role

Gastric lymphoma

primary gastric lymphoma V.S generalized lymphomatous

process.

the incidence of gastric lymphoma seems to be

increasing.
Primary gastric lymphoma accounts for approximately 5
% of all gastric neoplasms.
most common in the sixth decade
the presentation is no different from gastric cancer, the
common symptoms being pain, weight loss and bleeding.
Primary gastric lymphomas are B cell derived, the tumor
arising from the mucosa-associated lymphoid tissue
(MALT).

At an early stage, the disease takes the form of

a diffuse mucosal thickening, which may
ulcerate.
Diagnosis is made as a result of the
endoscopic biopsy.
Following diagnosis, adequate staging is
necessary, primarily to establish whether the
lesion is a primary gastric lymphoma or part of
a more generalized process. CT scans of the
chest and abdomen and bone marrow aspirate
are required, as well as a full blood count

the treatment of primary gastric lymphoma is

somewhat controversial, it seems most appropriate to
use surgery alone for the localized disease
process.

No benefit has been shown from adjuvant

chemotherapy, although some oncologists contend that
primary gastric lymphoma can be treated by
chemotherapy alone. Chemotherapy alone is
appropriate for patients with systemic disease.

Lymphocytes are not found to any degree in normal

gastric mucosa, but are found in association with
Helicobacter infection. It has also been shown that
early gastric lymphomas may regress and
disappear when the Helicobacter infection is
treated.

Gastric involvement with the diffuse

lymphoma

These patients are treated with chemotherapy,

sometimes with dramatic and rapid responses.
Surgeons are frequently asked to deal with the
complications of gastric involvement.
The two common complications are bleeding
and perforation. Both may occur at
presentation, but more usually may follow the
chemotherapy when there is rapid regression
and necrosis of the tumor. These operations can
be technically very challenging and normally
require gastrectomy