GASTRIC CANCERGASTRIC CANCER

GASTRIC CANCERGASTRIC CANCER 4%4% 5 5thth position position

22ndnd cause of cancer related cause of cancer related death in the worlddeath in the world

5 y survival rate5 y survival rate B:F=2:1B:F=2:1 More frequent in More frequent in JapJapan, Latin an, Latin AmericaAmerica, ,

Far East, North Europe. Far East, North Europe. Incidence is dropingIncidence is droping

PathologyPathology

AdenocarcinomAdenocarcinomaa 90% 90%SarcomSarcomaaLimfoLimfomama

CAUSESCAUSES 66-75% 66-75% can be prevented with diet using can be prevented with diet using

high quantity of fruits and vegetables and high quantity of fruits and vegetables and low in salty foods. low in salty foods.

Integral cereals and green teea can reduce Integral cereals and green teea can reduce the incidence the incidence

Vitamin C şi carotenoiVitamin C şi carotenoidsds probably decrease probably decrease the riskthe risk

AlcoAlcohhololmay increase the risk of GC in may increase the risk of GC in cardia region cardia region

Smoking increases the riskSmoking increases the risk

ETHIOLOGYETHIOLOGY Atriphic gastritis Atriphic gastritis 9% 9% will develop GCwill develop GC Chronic inflammationChronic inflammation – – destruction of glandsdestruction of glands – – lower capacity of lower capacity of

acid secretion – intestinal metaplasiaacid secretion – intestinal metaplasia CaCausesuses

Helicobacter pyloriHelicobacter pylori Ac anti parietalAc anti parietal cells cells – – Biermer Biermer Antral resection Antral resection

ETHIOLOGYETHIOLOGY Helicobacter pyloriHelicobacter pylori

Distal GC + association with atrophyDistal GC + association with atrophy Appears to be protective against procimal GC Appears to be protective against procimal GC 11// 97 97 infectet patients develop infectet patients develop CG CG Inf:noninf=8:1Inf:noninf=8:1, ONLY CERTAIN FENOTYPES, ONLY CERTAIN FENOTYPES

ETHIOLOGYETHIOLOGY PolPolyyppss

Hiperplastic – 80%Hiperplastic – 80% High risk overHigh risk over 0,5 0,5 ccmm

AdenomatoAdenomatoss Very high risckVery high risck

Familial riskFamilial risk 2-3X 2-3X higherhigher MutaMutation in genetion in gene

CHD1 CHD1 --E-cadherina E-cadherina role in diferencietion role in diferencietion and cel arhitectureand cel arhitecture

Molecular fenotypeMolecular fenotype c-met, K-sam ic-met, K-sam involved nvolved

in cell grothin cell groth p53 p53 suppressor genesuppressor gene– –

64%64% cyclin Ecyclin E

PATHOLOGYPATHOLOGY Intestinal Intestinal

AtrophyAtrophy – – metaplametaplasiasia - - displadisplasiasia – adenom – adenomaa - cancer- cancer

Difuz – linitDifuz – linitis is plasticaplastica Submucosal Submucosal

invasioninvasion

Macroscopic – Macroscopic – BorrmannBorrmann TTyyppe e I - polipoid I - polipoid well well

defined defined TTyyppee II – polip II – polipoid with oid with

marked infiltration marked infiltration TTyyppee III – III – ulceratio with ulceratio with

infiltrated margins infiltrated margins Tip IV – linitTip IV – linitis is plasti plasticaca

Microscopic – OMSMicroscopic – OMS AdenocarcinomAdenocarcinomaa – –

intestinal, difuintestinal, difusese AdenocarcinomAdenocarcinomaa papilar papilaryy AdenocarcinomAdenocarcinomaa tubular tubular Adenoacrcinom mucinos Adenoacrcinom mucinos

(>50% mucino(>50% mucinous cellsus cells)) Signet cells carcinomaSignet cells carcinoma

(>(>50% signet cells50% signet cells)) AAdenosdenosqquamosuamos carcinoma carcinoma Squamos cell carcinomaSquamos cell carcinoma Small cells carcinomaSmall cells carcinoma NondiferentiatedNondiferentiated altelealtele

Primary tumor (T): Tis = carcinoma in situ: intraepithelial tumor without invasion of lamina propria T1 = tumor invades lamina propria or submucosa T2 = tumor invades muscularis propria or subserosa T3* = tumor penetrates serosa (visceral peritoneum) without invasion of adjacent structures T4**,*** = tumor invades adjacent structures

*A tumor may penetrate the muscularis propria with extension into the gastrocolic or gastrohepatic ligaments or into the greater or lesser omentum without perforation of the visceral peritoneum. **Structures adjacent to the stomach include the spleen, transverse colon, liver, diaphragm, pancreas, abdominal wall, adrenal gland, kidney, small intestine, and retroperitoneum. ***Intramural extension to the duodenum or esophagus is classified by the depth of greatest invasion in any of these sites, including the stomach).

Regional lymph nodes (N): Include the perigastric nodes along the lesser and greater curvatures, and the nodes along the left gastric, common hepatic, splenic, and celiac arteries. N0 = no regional lymph node metastasis N1 = metastasis to 1–6 regional lymph nodes N2 = metastasis in 7–15 regional lymph nodes N3 = metastasis in more than 15 regional lymph nodes

Distant metastasis (M): M0 = no distant metastasis M1 = distant metastasis

GradingGrading G1 G1 -- well diferentiated well diferentiated->95% gland->95% glandss G2 – moderat diferenG2 – moderat diferentiatedtiated – 50-95% – 50-95%

glandglandss G3 – G3 – poor diferentiatedpoor diferentiated - <49% gland - <49% glandss

Adc tubular – G1Adc tubular – G1 Adc Adc signet cellssignet cells – G3 – G3 Adc Adc small celss and non diferetiated small celss and non diferetiated – G4 – G4

CLINICA CLINICA PRESENTATIONPRESENTATION SubjectivSubjectiv

General neoplastic simptomsGeneral neoplastic simptoms DispepsiaDispepsia UGI bleedingUGI bleeding

ObObjjectivectiv TumorTumor palpable palpable HepatomegalHepatomegaly, ascites, y, ascites,

jaundice, splenomagalyjaundice, splenomagaly Sister Mary Joseph –Sister Mary Joseph – sign sign

(umbilkical nodule) (umbilkical nodule) VirchowVirchow sign sign – – left left

supraclavicular LNsupraclavicular LN Krukenberg –ovarKrukenberg –ovarian MTSian MTS Blumer – Blumer – rectal palpable rectal palpable

mass mass Trousseau – Trousseau – migrating flebitis migrating flebitis Leser-Trelat – Leser-Trelat – sseboreborhheiceic

keratitiskeratitis LabLab

AnemiaAnemia OOcultcult bleeding bleeding ACE, CA 19.9 ACE, CA 19.9

Rx Rx barium barium

CT,CT, MRI MRI, echoendoscop, echoendoscopyy+biops+biopsyybrush brush citologcitologyy, laparoscop, laparoscopyy, , lapro echographylapro echography

COMPLICATIONSCOMPLICATIONSBleeding Bleeding PerforationPerforationObstructionObstructionPenetrationPenetration

TRTREEATMENTATMENT SURGICALSURGICAL RezecRezectiontion

R0 – R0 – complete, no complete, no microscopic tumor microscopic tumor leftleft

R1 – R1 – microscopic microscopic tumor left in situtumor left in situ

R2 – R2 – macrosocopic macrosocopic residual tumorresidual tumor

LimfadenectomLimfadenectomyy D1 – staD1 – stationstions 1-6 1-6 D2 – staD2 – stationstions 7-11 7-11 D3 – staD3 – stationstions 12-14 12-14 D4 – staD4 – stationstions 15-16 15-16

OmentectomOmentectomyy

Endoscopic Endoscopic treatmenttreatment

Mucosal resection in Mucosal resection in early gastric cancerearly gastric cancer

PaliativPaliativee SclerotSclerothheraperapyy Laser destructionLaser destruction StentStent

TRTREEATMENTATMENT ChCheemotmothheraperapyy

Neoadjuvant Neoadjuvant / / adjuvantadjuvant 5-FU, doxorubicin şi mitomycin C (FAM)5-FU, doxorubicin şi mitomycin C (FAM) ImmunochemoterapImmunochemoterapy – CHT bound to y – CHT bound to

specific tumoral ATB. Agspecific tumoral ATB. Ag RadioterapRadioterapyy

neoadjuvantneoadjuvant CChemoradiationhemoradiation

AdjuvantAdjuvant Major discussionsMajor discussions