Stomach Neoplasms
Professor Ravi KantFRCS (England), FRCS (Ireland),
FRCS(Edinburgh), FRCS(Glasgow), MS, DNB, FAMS, FACS, FICS,
Professor of Surgery
Stomach Neoplasm
Maltoma Lymphoma GIST CA stomach
Gastric Lymphoma
Most common primary GI Lymphoma .It’s increasing in frequency.
Presentation: Similar to gastric carcinoma. May reveal peripheral adenopathy,
abdominal mass or splenomegaly.
Diagnosis:
1.EGD 2.contrast GI x-ray.
3.CT guided fine needle biopsy.
Treatment :
Gastric Lymphoma Rx is Surgery(Other organs- preferred Rx of
Lymphoma is Chemotherapy or Radiotherapy)
Maltoma
Mucosa associated lymphoid tumour
MALTOMA
Aetiology= H Pylori Rx = Rx of H Pylori = Triple drugs
What are GIST…?? Gastrointestinal Stromal Tumors
are uncommon mesenchymal tumors that arise in the wall of the gastrointestinal tract
It is believed to originate from an intestinal pacemaker cell called the interstitial cell of Cajal.
Cajal cell
An intestinal pacemaker cell, has been proposed the cellular origin of GISTs. It has characteristics of both smooth muscle and neural differentiation on ultrastructural examination
KIT
role of the KIT and platelet-derived growth factor receptor (PDGFR) tyrosine kinase receptors
KIT receptor tyrosine kinase (KIT RTK)
KIT approximately 5% of GIST cells show
not activation and aberrant signaling of the KIT receptor, but rather mutational activation of a structurally related kinase, PDGFR- (PDGFRA).
90% rate of mutations seen in a more recent series searching for potential mutations in each of exons 11, 9, 13, and 17
CD117 CD34 Actin & Desmin
S-100
GIST ++ - -
Desmoid tumor
- + - -
True leiomyosarcoma
- - + -
Schwanoma
- - - +
Diagnosis
CT is the common mode of diagnosis
FDG PET is mandatory ►PET CT scan is ideal MR
GIST & chemoresistance
▲ P-glycoprotein [the product of the multidrug resistance-1 (MDR-1) gene]
▲ MDR protein
Distribution… Stomach 50-60% Small bowel 20-30% Large bowel 10% Esophagus 5% Else where in abdomen 5%
Symptoms… Abdominal pain Dysphagia Gastrointestinal bleeding Symptoms of bowel obstruction Small tumors may be
asymptomatic
Cytologically…
1. Spindle cell GISTs2. Epithelioid cell GISTs Although GISTs can
differentiate along either or both cell types, some show NO significant differentiation at all
Diagnosis…MUST BE DONE
IMMUNOCHEMICALLY
The CD34 antigen (70-78%) The CD117 antigen (72-94%)
Malignant Versus Benign
Size Mitotic count
Very Low risk
<2 cm <5/50 HPF
Low risk 2-5 cm <5/50 HPFIntermediat
e risk<5 cm
5-10 cm6-10/50 HPF<5/50 HPF
High risk >5 cm>10 cmAny size
>5/50 HPF Any count>10/50 HPF
predictors of survival
Male sex, Tumor size > 5cm Incomplete resection
significant on
multivariate analysis
Treatment… Surgical excision is primary treatment
option but recurrence rates are high Resistant to standard chemotherapy
regimens due to over-expression of efflux pumps
Radiation therapy limited by large tumor sizes and sensitivity of adjacent bowel
IMATINIB Since activation of Kit played a
crucial role in the pathogenesis of GIST, inhibition of Kit would be therapeutic
IMATINIB Orally bioactive tyrosine kinase
inhibitor Shown to be effective against
GIST tumors in two trials in the US and Europe reported in 2001 & 2002
Gastrointestinal Stromal Tumor ‘GIST’
Previously leiomyoma & leiomyosarcoma.
<1 % Rarely cause bleeding or obstruction. The origin: Intestinal Cells of Cajal ‘ICC;s’
autonomic nervous system. The distinction b\w benign & malignant is
unclear. In general terms, the larger the tumor & greater mitotic activity, the more likely to metastases.
The stomach is the most common site of GIST.
Usually are discovered incidentally on endoscopy or barium meal
The endoscopic biopsies may be uninformative as the overlying mucosa is usually normal
Small tumorswedge resection Larger onesgastrectomy
35
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GIST Case history-
submucosal Cajal Cell Gene KIT PGDRF Diagnosis CT PET
Rx Surgery Chemoresistanc
e Imatininb Sumanitib Prognosis Predictor factors
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GASTRIC CARCINOMA
GASTRIC NEOPLASM
Epithelial
Mesenchymal
1.PrimaryAdenocarcinomaGastrointestinal stromal tumors ‘GIST’Lymphoma
2. Secondary: invasion from adjacent tumors.
BenignBenign MalignantMalignant
Gastric Carcinoma
55 year old Japanese male who is living in Japan & working in industry.
DEFINITION Malignant lesion of the stomach.Epidemiology & Risk Factors
Can occur at any ageBut Peak incidenceIs 50-70 years old.
It is more aggressiveIn younger ages.
Japan has the world highest Rate of gastric cancer.
Studies have confirmed that incidence decline inJapanese immigrant to
America.
dust ingestion from a variety of industrial processes may be a risk.
Twice more commonIn male than in female
Incidence of Gastric Carcinoma:Japan 70 in100,000/yearEurope 40 in 100,000/yearUK 15 in 100,000/yearUSA 10 in 100,000/yearIt is decreasing worldwide.
Gastric Carcinoma:
Risk Factors
Predisposing :
1. Pernicious anaemia & atrophic gastritis (achlorhydra)2. Previous gastric resection3. Chronic peptic ulcer (give rise to 1%)4. Smoking.5. Alcohol.
Environmental:
1.H.pylori infection Sero(+)patients have 6-9 folds risk2.low socioeconomic Status3. nationality (JAPAN)4. Diet (prevention)
Genetic:
1.Blood group A2.HNPCC: Hereditary non-polyposis colon cancer.
Clinical PresentationMost patients present with advanced stage.. why?They are often asymptomatic in early stages.
Common clinical Presentation:The patient complained of The patient complained of loss of appetiteloss of appetite that was that was
followed by followed by weight lossweight loss of 10Kg in 4 weeks. of 10Kg in 4 weeks.
He had notice He had notice
epigastric discomfort & postprandial fullness.epigastric discomfort & postprandial fullness.
He presented to the ER complaining of He presented to the ER complaining of vomiting vomiting of of large quantities of undigested food & epigastric large quantities of undigested food & epigastric distension.distension.
Dyspepsia
epigastric painBloating early satiety nausea & vomiting* dysphagia* anorexia weight loss upper GI bleeding (hematemesis, melena, iron deficiency anemia)
signs
-Anemia.-Wt. loss ( cachexia)-Epigastric mass, Hepatomegaly, Ascitis -Jaundice.-Blumer’s shelf -Virchow's node-Sister Mary Joseph node -Krukenberg tumor-Irish node
Pathology DIO Classification
Lauren Classification:
1. Intestinal Gastric ca. It arises in areas of intestinal metaplasia to form polypoid tumors or ulcers.
2. Diffuse Gastric ca. It infiltrates deeply in the stomach without forming obvious mass lesions but spreads widely in the gastric wall “Linitis Plastica” & it has much more worse prognosis
3. Mixed Morphology.
Morphology
• Polypoid
• Ulcerative
• Superficial spreading
• Linitis plastica
Gastric cancer can be divided into:
Early: Limited to mucosa & submucosa with or
without LN (T1, any N) >> curable with 5 years survival rate in
90%.
Advanced: It involves the Muscularis. It has 4 types( Bormann’s
classification). Type III & IV are incurable.
T1 lamina propria & submucosa
T2 muscularis & subserosa
T3 serosa
T4 Adjacent organs
N0 no lymph node
N1 Epigastric node
N2 main arterial trunk
M0 No distal metastasis
M1 distal metastasis
Staging of gastric cancerSpread of Gastric Cancer
Direct Spread
Blood-borne metastasis
Lymphatic spread
Transperitonealspread
Tumor penetrates themuscularis, serosa & Adjacent organs(Pancreas,colon &liver)
What is important here isVirchow’s node (Trosier’s sign)
Usually with extensive Disease where liver 1st
Involved then lung &Bone
This is commonAnywhere in peritoneal cavity(Ascitis)Krukenberg tumor (ovaries)Sister Joseph nodule(umbilicus)
Complications Peritoneal and pleural effusion
Obstruction of gastric outlet or small bowel
Bleeding
Intrahepatic jaundice by hepatomegaly
Differential DiagnosisDifferential Diagnosis
1.Gastric ulcer
2.Other gastric neoplasms
3.Gastritis
4.Gastric Polyp
5.Crohns disease.
From history,Cancer is not relieved by antacids
Not periodicNot relieved by eating or vomiting.
INVESTIGATIONS
Full blood count –IDA- LFT,RFTAmylase & lipase.Serum tumor markers (CA 72-4,CEA,CA19-9) not specificStool examination for occult bloodCXR ,Bone scan.
Specific:UGI endoscopy with biopsy Double contrast studyCT, MRI & USLaparoscopry
EGD esophagogastroduodenoscopy
Diagnostic accuracy is 98%
if up to 7 biopsies is taken.
Double Contrast barium upper GI x-ray
Diagnostic accuracy 90%
WHY?
Diagnostic study of Choice
1.Early superficial gastric mucosal lesion can be missed.2. can’t differentiate b/w benign ulcer & Ulcerating adenocarcinoma.
X-ray showing Gastric ulcer With symmetrical radiating
Mucosal folds.By histology, no evidence of Malignancies was observed.
X-ray showing Extensive carcinoma involving the cardia & Fundus
Pyloric stenosis
CT,MRI & US:
Laparoscopy:
Help in assessment of wall thickness, metastases (peritoneum ,liver & LN)Help in assessment of wall thickness, metastases (peritoneum ,liver & LN)
Detection of peritoneal metastases Detection of peritoneal metastases
THE GOLD STANDARD It allows taking biopsies Safe (in experienced hands)
UGI ENDOSCOPY
UGI ENDOSCOPY,contd. You may see an ulcer (25%),
polypoid mass (25%), superficial spreading (10%),or infiltrative (Linitis plastica)-difficult to be detected-
Accuracy 50-95% it depends on gross appearance, size, location & no. of biopsies
IF YOU SEE ULCER ASK UR SELF…BENIGN OR MALIGNANT?
BENIGN MALIGNANTRound 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
Mostly on lesser curvature Anywhere
Majority<2cm Any size
Normal adjoining rugal folds that extend to the
margins of the base
Prominent & edematous rugal folds that usually do not extend to the margins
Management
• Surgery
• Chemotherapy NO PROVEN BENEFIT
• Radiotherapy
TreatmentTreatment
Initial treatment:
1.Improve nutrition if needed by parenteral or enteral feeding.
2.Correct fluid &electrolyte
& anemia if they are present.
Preoperative Care
Preoperative Staging is important because we don’t want to subject the patient to radical surgery that can’t help him.
PRE-OPERATIVE CARECareful preoperative stagingScreen for any nutritional deficiencies &
consider nutritional supportSymptomatic control Blood transfusion in symptomatic anemiaHydrationProphylactic antibioticsABO & cross matchAsk about current medications &
allergiesCessation of smoking
BASIC SURGICAL PRINCIPLES
3 TYPES: TOTAL,SUBTOTAL,PALLIATIVE
ANTRAL DISEASESUBTOTAL GASTRECTOMY
MIDBODY & PROXIMAL TOTAL GASTRECTOMY
TOTAL (RADICAL) GASTRECTOMY
o Remove the stomach +distal part of esophagus+ proximal part of duodenum + greater & lesser omentum + LN
o Oesophagojejunostomy with roux-en-y .
SUBTOTAL GASTRECTOMY
Similar to total one except that the PROXIMAL PART of the stomach is preserved
Followed by reconstruction & creating anastomosis
( by gastrojejunostomy, Billroth II )
PALLIATIVE SURGERY
• For pts with advanced (inoperable) disease & suffering significant symptoms e.g. obstruction, bleeding.
• Palliative gastrectomy not necessarily to be radical, remove resectable masses & reconstruct (anastomosis/intubation/stenting/
recanalisation)
POSTOPERATIVE ORDERS
• Admit to PACU
• Detailed nutritional advise (small frequent meals)
Post-Operative Complications
1.1.Leakage from duodenal stump.
2.2.Secondary hemorrhage.
3.3.Nutritional deficiency in long term.
2.Chemotherapy: Responds well, but there is no effect on
survival.Marsden RegimenEpirubicin, cisplatin &5-flurouracil (3 wks)6 cyclesResponse rate : 40% .
3. Radiotherapy: Postperative-radiotherpy: may decrease the
recurrence.
Preventive measuresPreventive measuresBy dietBy dietConvincing:Convincing:vegetable & fruits.Probable:Probable: Vit. C &EPossiblePossible
Carotenoids, whole grain cereals and green tea.
Smoking cessation
Cessation of alcohol intake
Early diagnosis remains the Key Problem
PROGNOSTIC FEATURES2 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
E-medicine web siteThe Washington Manual of Surgery
Bailey & Love’s short practice of surgeryClinical surgery ( A. Cuschieri).