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    Gastric Carcinoma: Professor Ravi Kant

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    Vasanth Malagi
    Gastric carcinoma is a malignant lesion of the stomach that is most common in Japan. Risk factors include H. pylori infection, smoking, low socioeconomic status, and family history of certain cancers. Patients often present with nonspecific symptoms like weight loss, abdominal pain, and vomiting. Diagnosis is made through endoscopy with biopsy. Treatment involves surgery such as total or subtotal gastrectomy depending on location of tumor. Prognosis depends on depth of invasion and lymph node involvement, with 5-year survival rates as high as 50% in Japan.

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    Gastric Carcinoma: Professor Ravi Kant

    Uploaded by

    Vasanth Malagi
    56 views44 pages
    Gastric carcinoma is a malignant lesion of the stomach that is most common in Japan. Risk factors include H. pylori infection, smoking, low socioeconomic status, and family history of certain cancers. Patients often present with nonspecific symptoms like weight loss, abdominal pain, and vomiting. Diagnosis is made through endoscopy with biopsy. Treatment involves surgery such as total or subtotal gastrectomy depending on location of tumor. Prognosis depends on depth of invasion and lymph node involvement, with 5-year survival rates as high as 50% in Japan.

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    Gastric Carcinoma

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    Gastric carcinoma is a malignant lesion of the stomach that is most common in Japan. Risk factors include H. pylori infection, smoking, low socioeconomic status, and family history of certain cancers. Patients often present with nonspecific symptoms like weight loss, abdominal pain, and vomiting. Diagnosis is made through endoscopy with biopsy. Treatment involves surgery such as total or subtotal gastrectomy depending on location of tumor. Prognosis depends on depth of invasion and lymph node involvement, with 5-year survival rates as high as 50% in Japan.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    56 views44 pages

    Gastric Carcinoma: Professor Ravi Kant

    Uploaded by

    Vasanth Malagi
    Gastric carcinoma is a malignant lesion of the stomach that is most common in Japan. Risk factors include H. pylori infection, smoking, low socioeconomic status, and family history of certain cancers. Patients often present with nonspecific symptoms like weight loss, abdominal pain, and vomiting. Diagnosis is made through endoscopy with biopsy. Treatment involves surgery such as total or subtotal gastrectomy depending on location of tumor. Prognosis depends on depth of invasion and lymph node involvement, with 5-year survival rates as high as 50% in Japan.

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    of 44

    GASTRIC CARCINOMA

    Professor Ravi Kant


    FRCS (England), FRCS (Ireland),
    FRCS(Edinburgh), FRCS(Glasgow), MS, DNB,
    FAMS, FACS, FICS,
    Professor of Surgery
    GASTRIC NEOPLASM
    Benign Malignant

    Epithelial 1.Primary
    Mesenchymal Adenocarcinoma
    Gastrointestinal stromal tumors
    ‘GIST’
    Lymphoma

    2. Secondary:
    invasion from adjacent tumors.
    Gastric Carcinoma
    Epidemiology
    DEFINITION &Malignant
    Risk Factors
    lesion of the stomach.

    55 year old Japanese male who is living in


    Incidence of Gastric
    Japan & working in industry.
    Carcinoma:
    Japan 70 in100,000/year
    Europe 40 in 100,000/year Twise more common
    UK 15 in 100,000/year In world
    Japan has the male than in female
    dust ingestion
    Can occur
    USA 10 in at any agehighest Rate of
    100,000/year from a variety
    Studies
    But Peak have confirmed
    incidece
    It is decreasing
    thatyears worldwide.
    incidence gastric cancer. of industrial
    Is 50-70 old. decline in
    Japanese
    It is more immigrant to
    aggressive processes
    America.
    In younger ages. may be a risk.
    Gastric Carcinoma:
    Risk Factors

    Predisposing : Environmental: Genetic:

    1. Pernicious anemia 1.H.pylori infection 1.Blood group A


    & atrophic gastritis Sero(+)patients 2.HNPCC:
    (achlorhydra) have 6-9 folds risk Heriditory non-
    2. Previous gastric 2.low polyposis colon
    resection socioeconomic cancer.
    3. Chronic peptic ulcer Status
    (give rise to 1%) 3. Nationality
    4. Smoking. (JAPAN)
    5. Alcohol. 4. Diet (prevention)
    Clinical Presentation
    Most patients present with advanced stage..
    why?
    They are often asymptomatic in early stages.

    Common clinical Presentation:


    The patient complained of loss of appetite that was
    epigastric pain
    followed by weight loss of 10Kg in 4 weeks.
    Bloating
    Heearly
    hadsatiety
    notice
    nausea & vomiting*
    epigastric
    dysphagia* discomfort & postprandial fullness.
    He presented to theDyspepsia
    anorexia ER complaining of vomiting of
    weight quantities
    large loss of undigested food & epigastric
    upper GI bleeding
    distension.
    (hematemesis, melena,
    iron deficiency anemia)
    signs
    -Anemia.
    -Wt.loss ( cachexia)
    -Epigastric mass,Hepatomegaly,Ascitis
    -Jaundice.
    -Blumers shelf
    -Virchows 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 devided 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.
    Spread
    Stagingof
    ofGastric
    gastric Cancer
    cancer

    T1 lamina propria & submucosa


    Direct Spread Lymphatic spread
    T2 muscularis & subserosa
    T3Tumor penetrates the
    serosa
    muscularis, serosa &
    What is important here is
    Virchow’s node
    T4Adjacent
    Adjacentorgans organs (Trosier’s sign)
    (Pancreas,colon &liver)
    N0 no lymph node
    Blood-bornenode
    N1 Epigastric Transperitoneal
    metastasis spread
    N2 main arterial trunk
    Usually with extensive This is common
    M0Disease
    No distal metastasis
    where liver 1st Anywhere in peritoneal cavity
    (Ascitis)
    M1Involved
    distal then lung &
    metastasis
    Bone Krukenberg tumor (ovaries)
    Sister Joseph nodule
    (umbilicus)
    Complications
     Peritoneal and pleural effusion

     Obstruction of gastric outlet or small bowel

     Bleeding

     Intrahepatc jaundice by hepatomegaly


    Differential Diagnosis
    1.Gastric ulcer
    From history,
    Cancer is not relieved by antacids
    Not periodic
    Not releived by eating or vomiting.

    2.Other gastric neoplasms


    3.Gastritis
    4.Gastric Polyp
    5.Crohns disease.
    INVESTIGATIONS
    Full blood count –IDA-
    LFT,RFT
    Amylase & lipase.
    Serum tumor markers (CA 72-4,CEA,CA19-9)
    not specific
    Stool examination for occult blood
    CXR ,Bone scan.
    Specific:
    UGI endoscopy with biopsy
    Double contrast study
    CT, MRI & US
    Laparoscopry
    EGD esophagogastroduodenoscopy
    Diagnostic accuracy is 98%
    if upto 7 biopsies is taken.

    Diagnostic study of Choice

    Double Contrast barium upper GI x-ray


    Diagnostic accuracy 90%
    WHY?
    1.Early superficial gastric mucosal lesion
    can be missed.
    2. can’t differentiate b/w benign ulcer &
    Ulcerating adenocarcinoma.
    X-ray showing Extensive
    carcinoma involving
    X-ray showing Gastric ulcer the cardia & Fundus
    With symmetrical radiating
    Mucosal folds.
    By histology, no evidence of
    Malignancies was observed.

    Pyloric stenosis
     CT,MRI & US:

    Help in assessment of wall thickness,


    metastases (peritoneum ,liver & LNs)

     Laparoscopy:
    Detection of peritoneal
    metastases
    UGI ENDOSCOPY
    THE GOLD STANDARD
     It allows taking biopsies
     Safe (in experienced hands)
    UGI ENDOSCOPY,contd.
     You may see an ulcer (25%),
    polypoid mass (25%), superficial
    spreading (10%),or infiltrative
    (linnitis 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 MALIGNANT
    Round to oval punched out Irregular outline with
    lesion with straight walls & necrotic or hemorrhagic
    flat smooth base base
    Smooth margins with Irregular & raised margins
    normal surrounding
    mucosa
    Mostly on lesser curvature Anywhere

    Majority<2cm Any size

    Normal adjoining rugal Prominent & edematous


    folds that extend to the rugal folds that usually do
    margins of the base not extend to the margins
    Management
    • Surgery

    • Chemotherapy
    NO PROVEN BENEFIT

    • Radiotherapy
    Treatment
    Initial treatment:
    1.Improve nutrition if Preoperative Care
    needed by parentral Preoperative Staging is
    or enteral feeding. important because we
    don’t want to subject
    2.Correct fluid
    the patient to radical
    &electrolyte
    surgery that can’t help
    & anemia if they are him.
    present.
    PRE-OPERATIVE CARE
     Careful preoperative staging
     Screen for any nutritional deficiencies &
    consider nutritional support
     Symptomatic control
     Blood transfusion in symptomatic anemia
     Hydration
     Prophylactic antibiotics
     ABO & crossmatch
     Ask about current medications & allergies
     Cessation of smoking
    BASIC SURGICAL PRINCIPLES

    3 TYPES:
    TOTAL,SUBTOTAL,PALLIATIVE
     ANTRAL DISEASESUBTOTAL
    GASTRECTOMY
     MIDBODY & PROXIMAL TOTAL
    GASTRECTOMY
    TOTAL (RADICAL) GASTRECTOMY

    o Remove the stomach +distal part


    of esophagus+ proximal part of
    dudenum + greater & lesser
    omenta + LNs
    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.Leakage
    1. from
    duodenal stump.

    2.Secondary
    2.
    hemorrhage.

    3.Nutritional
    3.
    deficiency in long
    term.
    2.Chemotherapy:
    Responds well, but there is no effect on servival.
    Marsden Regimen
    Epirubicin, cisplatin &5-flurouracil (3 wks)
    6 cycles
    Response rate : 40% .
    3. Radiotherapy:
    Postperative-radiotherpy: may decrease the
    recurrence.
    Preventive measures
    By diet
    Convincing:
    vegetable & fruits.
    Early diagnosis remains the Key
    Probable:
    Vit.C &E
    Problem
    Possible
    Carotenoids,whole grean cereals and green tea.
    Smoking cessation
    Cessation of alcohol intake
    PROGNOSTIC FEATURES
    2 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
    Gastrointestinal Stromal Tumor ‘GIST’

     Previously leiomyoma & leomyosarcoma.


     <1 %
     Rarly cause bleeding or obstruction.
     The origion: 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 bcz the overlying mucosa is
    usually normal
    Small tumorswedge resection
    Larger onesgastrectomy
    Gastric Lymphoma

    Most common primary GI Lymphoma .


    It’s increasing in frequency.

    Presentation:
    Similar to gastric carcinoma.
    May reveal peripheral adenopathy,
    abdominal mass or spleenomegaly.
    Diagnosis:
    1.EGD 2.contrast GI x-ray.
    3.CT guided fine needle biopsy.
    Treatment :
    1. surgery: total or subtotal gastrectomy with
    spleenectomy or palliative resection.
    2.Adjunct radiotherapy: may improve 5 year
    survival
    3.Adjunct Chemotherapy: may prevent recurrance.
    Bailey & Love’s short practice of
    surgery E-medicine web site
    Clinical surgery ( A.cuschieri). The Washington Manual of Surg

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