STAGING AND MANAGEMENT OF CA STOMACH

STAGING AND MANAGEMENT OF CA STOMACHBY Dr DEEPAK KUMAR DASMOD- Dr NARENDRA KUMARPGIMER, CHANDIGARH

EPIDEMIOLOGYCarcinoma stomach is the 2nd leading cause of cancer related death behind lung cancer.The highest incidences are found in East Asia (Japan and China)> South America > Eastern Europe RISK FACTORSACQUIRED FACTORSH. Pylori infection ( 3-6 times)- distal gastric cancer and intestinal typeHigh intake of smoked and salted foodsNitratesDiet low in fruits and vegetablesSmoking Obesity proximal gastric lesionsBarrett esophagus/GERDPrior subtotal gastrectomy (25%)RT exposure

GENETIC FACTORS E- cadherin (CDH-1 gene) Type A blood group Pernicious anemia (5-10%) HNPCC Li-Fraumeni syndrome

PATHOLOGICAL CLASSIFICATION OF GASTRIC CANCERAdenocarcinoma- 90 to 95%LymphomaGISTAdenocanthomaSquamous cell carcinoma

LAURENS CLASSIFICATION2 histological types of adenocarcinomaINTESTINAL TYPEDifferentiated cancer with tendency to form glandsOccur in the distal stomachArise from precursor lesions seen mostly in endemic areas and in older peopleMore common in malesRisk factor is maily inflammatory and enviornmental factorsDIFFUSE TYPELess differentiated- signet ring cell, mucin producingHave extensive submucosal and distant spreadTend to be proximalMore common in women and younger peopleGenetic etiology

1926, 4 macroscopic tumor growth patterns: Type I, nodular polypoid tumor without ulceration and usually with a broad base;Type II- fungating, exophytic, circumscribed tumor with defined sharp margins, devoid of ulceration except at its domeType III- ulcerating tumor + penetrating, infiltrating ulcer base; Type IV - diffuse thickening of the gastric wall with no discretely marginated mass or ulceration,leather bottle,linitis plastica.

BORRMANS CLASSIFICATION

DIRECT- Omenta, Pancreas, Diaphram, Transverse colon, Mesocolon, Duodenum, Jejunum, Spleen, Liver, Adrenals, Kidney.LYMPHATICS- submucosal to oesophagus and duodenum- Initial along greater and lesser curvature,Primary drain to all three branches of celiac axis- L gastri, Comm Hepatic, Splenic ,Lately to - hepato duodenal, peripancreatic, root of mesentry periaortic, middle colic. HEMATOGENOUS- liver lungPERITONEAL INVOLVEMENTPATHWAYS OF SPREAD

CLINICAL PRESENTATIONLoss of appetiteEarly satietyAbdominal discomfortUnintentional weight lossNausea and vomitingTarry stoolDuration of symptom is 1 year in 20%.PHYSICAL EXAMINATIONCan reveal advanced diseaseAbdominal mass -Epigastric or liver mass, periumbilical node (Sister Mary Joseph node)Palpable left supraclavicular node (Virchows node)Rectal shelf (Blumers shelf)

DIAGNOSTIC WORK UPUGIE- Direct visualisation, cytology and biopsy yields the diagnosis in >90% of exophytic lesionsInfiltrative( linitis plastica), small (