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GASTRIC TUMOURS

GASTRIC TUMOURS.  Anatomy of the stomach  Aetiology of Gastric cancer  Types of Gastric cancer  Pathology of Gastric Cancer  Evaluation of Gastric Cancer  Treatment of Gastric Cancer. ANATOMY :.

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GASTRIC TUMOURS

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  1. GASTRICTUMOURS Anatomy of the stomach Aetiology of Gastric cancer Types of Gastric cancer Pathology of Gastric Cancer Evaluation of Gastric Cancer Treatment of Gastric Cancer

  2. ANATOMY: The stomach J-shaped. The stomach has two surfaces (the anterior & posterior), two curvatures (the greater & lesser), two orifices (the cardia & pylorus). It has fundus, body and pyloric antrum.

  3. BLOODSUPPLY: a.The left gastric artery b.Right gastric artery c.Right gastro-epiploic artery d.Left gastro-epiploic artery e.Short gastric arteries The corresponding veins drain into portal system. The lymphatic drainage of the stomach corresponding its blood supply.

  4. Anatomy • Stomach has five layers: • Mucosa • Epithelium, lamina propria, and muscularis mucosae* • Submucosa • Smooth muscle layer • Subserosa • Serosa

  5. AETIOLOGY:  Gastric cancer is the second most common fatal cancer in the world with high frequency in Japan. The disease presents most commonly in the 5th and 6th decades of life and affect males twice as often as females. Contn…

  6. The cause of the disease multistep process but several predisposing factors attributed to cause the disease : a.Environmente.Atrophic gastritis b.Dietf.Chronic gastric ulcer c.Heredity g.Adenomatous polyps d.Achlorhydriah.Blood group A i.H. Pyloric colonisation

  7. TYPESOFGASTRICCANCER: A.Benign Tumours B.Malignant Tumours

  8. TYPESOFGASTRICCANCER: A.Benign Tumours B.Malignant Tumours

  9. THEBENIGNTUMORS: Although benign tumors can occur in the stomach most gastric tumours are malignant.

  10. The benign groups includes:- 1.Non-neoplastic gastric polyps 2.Adenomas 3.Neoplastic gastric polyps 4.Smooth muscles tumours benign (Leiomyomas) 5.Polyposis Syndrome (eg:- Polyposis coli, Juvenile polyps and P.J. Syndrome) 6.Other benign tumours are fibromas, neurofibromas, aberrat pancreas and angiomas.

  11. PATHOLOGYOFGASTRIC(MALIGNANT)TUMOURS:  The gastric cancer may arise in the antrum (50%), the gastric body (30%), the fundus or oesophago-gastric juntion (20%).

  12. TypesofMalignantTumours: a.Adenocarcinoma b.Leiomyosarcoma c.Lymphomas d.Carcinoid Tumours

  13. The macroscopic forms of gastric cancers are classified by (Bormann classification) into:- 1.Polypoid or Proliferative 2.Ulcerating 3.Ulcerating/Infiltrating 4.Diffuse Infiltrating (Linnitus- Plastica)

  14. Microscopically the tumours commonly adenocarcinoma with range of differentiation. The most useful to clinician and epidemiologist is Lauren Histological Classification: a.Intestinal gastric cancer b.Diffuse gastric cancer

  15. Diffuse M:F 1:1 Onset Middle Age 5 yr surv overall <10% Aetiology Diet H. pylori Intestinal M:F 2:1 Onset Middle Age 5 yr surv overall 20% Aetiology Unknown Blood group A association H. pylori Gastric Carcinoma

  16.  Early Gastric Cancer:Defined as cancer whichis confined to the mucosa and submucosa regard- less of lymph nodes status.  Advanced Gastric Cancer: Defined as tumor that has involved the muscularis propria of the stomach wall.

  17. Pathology: Gastric dysplasia ---> precursor of gastric CA Early gastric cancer: Limited to the mucosa and submucosa, regardless of LN status 70% are well differentiated Cure rate is 90% Gastric Neoplasm:

  18. STAGINGOFGASTRICCANCER: a.TNM System b.CT Staging c.PHNS Staging System (Japanese) P-factor (Peritoneal dissemination)  H-factor (The presence of hepatic metastases) N-factor (Lymphnodes involvement) S-factor (Serosal invasion)

  19. TNM Classification System • Distant metastasis (M) MX Presence of distant metastasis cannot be assessed M0 No distant metastasis M1 Distant metastasis (may be further specified according to size of occurrence)

  20. SPREADOFGASTRICCANCER:  The diffuse type spreads rapidly through the submucosal and serosal lymphatic and penetrates the gastric wall at early stage, the intestinal variety remains localized for a while and has less tendency to disseminate. The spread by: 1.Direct (loco regional) 2.Lymphatic 3.Blood (Haematogenous) 4.Transcoelomic

  21. Clinical Manifestation: • Weight loss due to anorexia and early satiety is the most common symptoms • Abdominal pain (not severe) common • Nausea / vomiting • Chronic occult blood loss is common; GIT bleeding (5%) • Dysphagia (cardia involvement)

  22. Clinical Manifestation: • Paraneoplastic syndromes ( Trousseau’s syndrome – thrombophlebitis; acanthosis nigricans – hyperpigmentation of axilla and groin; peripheral neuropathy) • Signs of distant metastasis: • Hepatomegally / ascites • Krukenbergs tumor • Blummers shelf (drop metastasis) • Virchow’s node • Sister Joseph node (pathognomonic of advances dse)

  23. SUMMARY:  Often asymptomatic until late stage.  Marked weight loss  Anorexia  Feeling of abdominal fullness or discomfort  Epigastric mass Iron Deficiency Anaemia Left supraclavicular mass (Troisier’s Sign) Obstructive Jaundice (Secondary in porta hepatitis)  Pelvic mass (Krukenberg)

  24. EVALUATIONOFGASTRICCANCER: History Clinical Examination Investigations The clinical features of gastric cancer may arise from local disease, its complications or its metastases.

  25. INVESTIGATIONS: A.Upper gastero intestinal endoscopy with multiple biopsy and brush cytology B.Radiology: CT Scan of the chest and abdomen USS upper abdomen Barium meal C.Diagnostic laparoscopy

  26. Diagnosis: • UGIS (double contrast) • Endoscopy (Biopsy / Ultrasound) • GOLD STANDARD • Best pre-operative staging • Needle aspiration of LN w/ ultrasound guidance • Can even give preop neoadjuvant tx • CT scan (intravenous and oral contrast): • For pre-operative staging • Whole body Positron Emission Tomography scanning (PET): • Tumor cell preferentially accumulate positron-emitting 18F fluorodeoxyglucose.

  27. Laboratory • Assists in determining optimal therapy. • CBC identifies anemia, with may be caused by bleeding, liver dysfunction, or poor nutrition. • 30% have anemia. • Electrolyte panels and LFTs are also essential to better characterize patients clinical state.

  28. Investigations for patients with gastric cancer • Endoscopy & biopsy • Performance status • Physiological assessment • Cardio-pulmonary function • CT chest & abdomen • EUS (endoscopic ultrasound) • Laparoscopy

  29. CT scanning • Technique • Spiral CT of chest and abdomen

  30. Laparoscopy • Inspect peritoneal surfaces, liver surface. • Identification of advanced disease avoids non-therapeutic laparotomy in 25%. • Patients with small volume metastases in peritoneum or liver have a life expectancy of 3-9 months, thus rarely benefit from palliative resection.

  31. Screening of Gastric Cancer • Patients at risk for gastric CA should undergo yearly endoscopy and biopsy: • Familial adenomatous polyposis • Hereditary nonpolyposis colorectal cancer • Gastric adenomas • Menetrier’s disease • Intestinal metaplasia or dysplasia • Remote gastrectomy or gastrojejunostomy

  32. TREATMENTSOFGASTRICCANCER: Surgery(Early or Advanced Cancer)  Distal tumours which involve the lower ½ (sub-total or partial gasterectomy). Proximal tumours which involve the fundus, cardia or body (total gasterectomy).

  33. Surgical Treatment

  34. TREATMENT: SURGERY: • The only curative tx for gastric cancer • Except: • Can’t tolerate abdominal surgery • Overwhelming metastasis • Palliation is poor w/ non-resective operations • GOAL: resect all tumors, w/ negative margins (5cm) and adequate lymphadenectomy (need for RFS) • Enbloc resection of adjacent organ is done if needed.

  35. TREATMENT: SURGERY: Radical subtotal gastrectomy Standard operation for gastric cancer Organs resected: Distal 75% of stomach 2 cm of duodenum Greater & lesser omentum Ligation of R & L gastric artery and gastroepiploic vesels Billroth II gastojejunostomy

  36. TREATMENT: SURGERY: Radical subtotal gastrectomy Standard operation for gastric cancer If gastric remnant left is small (<20%) do Roux-en-Y reconstruction

  37. Endoscopic Resection of Gastric Carcinoma Criteria: • Tumor < 2cm in size • Node negative • Tumor confined on the mucosa Nodes metastasis is < 1%: • No mucosal ulceration • No lymphatic invasions • <3cm tumor

  38. Treatment of gastric cancer • Endoscopic treatment • EMR (endoscopic mucosal resection) • ablation • Surgery • Multimodal treatment • Neo-adjuvant • Adjuvant • Palliative treatment

  39. Endsocopic mucosal resection • T1 mucosal disease • Minimal risk of LN metastases • Various techniques • Specimen obtained

  40. Distal Pancreatectomy • Associated with marked increase in morbidity & mortality with or without splenectomy • Indications for pancreatectomy: • Direct invasion of the tail of the pancreas • Likelihood of splenic artery nodal involvement

  41. Surgical Treatment

  42.  Inoperable tumours: Whenever possible it is advisable to do even a limited gastric resection. If resection is impossible an anterior gastrojejunostomy.

  43. Indications for Splenectomy • If macroscopic disease can be resected & the operation is potentially curative then en bloc splenectomy or pancreaticosplenectomy is worthwhile. • If it is more palliative then this benefit must be weighed against the potential complications of splenectomy and more extensive operation

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