gastric carcinoma
TRANSCRIPT
THE GASTRICCARCINOMA
Prof. Faisal Ghani SiddiquiFCPS; PGDip-bioethics; MCPS-HPE
Preamble
• Epidemiology• Aetiologic factors• Pathology• Clinical features• Investigations• Treatment
Adenocarcinoma -Epidemiology
• Incidence in USA/western Europe• Leading cause of death in Asia/Eastern
Europe• Elderly• Blacks• Low SE status
What causes Gastric Cancer?
Gastric Cancer
• Pernicious anaemia• Blood group A• Family history of gastric cancer
Gastric Cancer Diet
• High fat diet• Pickled, preserved food• Tobacco• Fresh fruit and vegetables• Vitamin C• Regular aspirin
Gastric CancerGenetic Mutations
• Deletion or suppression of p53• Overexpression of COX-2• CDH1
Gastric Cancer Pre-malignant
Conditions• Polyps• Atrophic gastritis• Benign gastric ulcer• Gastric ramnant
Gastric CancerPathology
Malignant Neoplasms of the Stomach
PrimaryAdenocarcinoma (94%)Lymphoma (4%)Malignant GIST (1%)
Haematogenous spreadBreastMalignant melanoma
Direct invasionPancreas; Liver; colon; ovary
Gastric CancerGross Appearance
PolypoidFungatingUlcerativeScirrhous
Gastric CancerHistology –Lauren
Classification
IntestinalDiffuse
Unclassified
Gastric CancerTNM staging
Tis Intaepithelial tumourT1 Tumour invades LP or submucosaT2 Tumour invades muscularis propria or
subserosaT3 Tumour penetrates serosa without
invasion of adjacent structuresT4 Tumour invades adjacent structures
Gastric CancerTNM staging
N0 No regional lymph node metastasesN1 Metastasis in 1 to 6 regional lymph
nodesN2 Metastasis in 7 to 15 regional lymph
nodesN3 Metastasis in more than 15 regional
lymph nodes
Gastric CancerTNM staging
M0 No distant metastasisM1 Distant metastasis
Gastric CancerClinical Manifestations
Symptoms• Weight loss• Decreased food intake• Abdominal pain• Nausea, vomiting and bloating• Acute GI bleeding• Chronic GI bleeding• Dysphagia
Trousseau’s syndrome(thrombophlebitis)
Acanthosis
Nigracans
Clinical Signs
• Cervical, supraclavicular and axillary lymphadenopathy
• Pleural effusion• Aspiration pneumonitis• Abdominal mass• Sister Joseph’s nodule• Ascites• Rectal shelf of Blumer
Rudolph Virchow
Gastric CancerDiagnostic Evaluation
Prompt upper endoscopy if …• New onset of dyspepsia >45 years• Dyspepsia with alarm symptoms
(weight loss, anaemia, recurrent vomiting, bleeding)
• Dyspepsia & family h/o gastric carcinoma
Preoperative Staging
• Abdominal / pelvic CT scanning• Endoscopic ultrasound (EUS)– Depth of the tumour– Enlarged perigastric/coeliac lymph
nodes
Gastric CancerTreatment
Surgical Resection & Adequate
Lymphadenectomyis the only curative treatment
except• Metastases• Co-morbid
Surgical Resection
• Resection of tumour• Grossly negative margin of at least 5 cms • Partial gastrectomy• Confirmed on frozen section• En block resection of adjacent involved
organs
Extent of Gastrectomy
• Radical subtotal gastrectomy (Distal tumour)
• Total gastrectomy(Proximal tumour)
Lymphadenectomy
• D1: stations 3-6• D2: stations 1,2, 7,8 and 11• D3: stations 9, 10 and 12
Survival benefit to adjuvant radio-chemotherapy
is marginal in patients who have undergone adequate resection
In gross unresectable, metastatic tumour
Role of palliative chemotherapy
is uncertain