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Gastric Carcinoma

Gastric Carcinoma. Incidence/Prevalence. Adenocarcinoma - 90% intestinal (decreasing trend) diffuse (increase trend) Non-Hodgkin's lymphoma - 6% GIST Carcinoid Squamous cell Ca. Incidence/Prevalence. 3 rd most common GI malignancy (after colorectal and pancreatic)

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Gastric Carcinoma

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  1. Gastric Carcinoma

  2. Incidence/Prevalence • Adenocarcinoma - 90% • intestinal (decreasing trend) • diffuse (increase trend) • Non-Hodgkin's lymphoma - 6% • GIST • Carcinoid • Squamous cell Ca

  3. Incidence/Prevalence • 3rd most common GI malignancy (after colorectal and pancreatic) • Second causes of death from cancer • lung (17.8 %), gastric (10.4 %), and liver (8.8 %) • The worldwide incidence of gastric cancer has declined rapidly over the recent few decades • Part of the decline may be due to the recognition of certain risk factors such as H. pylori and other dietary and environmental risks • Despite the decline, the absolute number of new cases per year is increasing

  4. GEOGRAPHICAL VARIATION • The incidence of gastric cancer varies with different geographic regions. • Approximately 60 percent of gastric cancers occur in developing countries • The highest incidence rates are in Eastern Asia, the Andean regions of South America, and Eastern Europe • Japan & S. America  75 & 150 / 100,000 • US & W.Europe  8 & 15 / 100,000

  5. Incidence/Prevalence • Early Gastric Carcinoma • Japan  40 % • United States  6 -10 %

  6. Incidence/Prevalence • Slowly developing • Usually discovered in advanced stages • Men>Women • Occurs between the ages of 50-70

  7. ENVIRONMENTAL RISK FACTORS •  Emigrants from high-incidence to low-incidence countries often experience a decreased risk of developing gastric carcinoma. • Diet  • Foods such as pickled vegetables, salted fish and meat, smoked foods and salt • Salt — High salt intake damages stomach mucosa and increases the susceptibility to carcinogenesis in rodents • Dietary nitrates (bacteria in stomach breaks down nitrites to compounds that are carcinogenic in animals)

  8. ENVIRONMENTAL RISK FACTORS • People who smoke cigarettes or use alcohol are 1.5 times more likely • Socioeconomic status  -The risk of distal gastric cancer is increased by approximately twofold in populations with low socioeconomic status - By contrast, proximal gastric cancers have been associated with higher socioeconomic class

  9. ENVIRONMENTAL RISK FACTORS • H. pylori: Important in the etiology of peptic ulcers and gastric cancer • Found in 60 percent of gastric carcinomas • Gastric surgery • increased risk of gastric cancer after gastric surgery Billroth II procedure , with the risk being greatest 15 to 20 years after surgery

  10. RISK FACTORS • Gastric polyps • Gastric ulcer • Genetic factors include: • First degree relatives • Type A blood • Pernicious anemia

  11. Anatomy of Stomach Cardia Pylorus Body Antrum

  12. Stomach-normal histology • Parietal cells - in body produce HCl • Chief cells - in body - pepsinogen • Mucous cells - all over - mucus • G cells-in antrum - gastrin

  13. Anatomy of the stomach

  14. Location • 37% in the proximal third of the stomach • 30% in the distal stomach • 20% in the midsection • Remaining 13% in the entire stomach

  15. Gastric CarcinomaLauren Classification • There are two main histologic variants of gastric adenocarcinoma. • The most frequent is the "intestinal type", so called because of its morphologic similarity to adenocarcinomas arising in the intestinal tract. • The less common diffuse type gastric cancers

  16. Gastric CarcinomaLauren Classification • Intestinal • patients greater than 50, male>female • arises from metaplastic glands in chronic gastritis; associated with H. pylori • incidence decreasing in USA • Diffuse (signet ring cell, linitis plastica) • younger patients, no gender preference • not associate with H. pylori • incidence increasing

  17. Intestinal type • One model for the "intestinal type" of gastric cancer describes a progression from chronic gastritis to chronic atrophic gastritis, to intestinal metaplasia, dysplasia, and eventually to adenocarcinoma

  18. Morphologic types of Carcinoma Stomach Fungating Ulcerating Diffuse

  19. Ulcerated gastric adenocarcinoma

  20. Thickened “linitis plastica” type adenocarcinoma infiltrating gastric wall

  21. Physical Assessment • Early gastric cancer • Abdominal discomfort initially relieved with antacids • Feeling of fullness • Epigastric, back, or retrosternal pain • NOTE: most people will show no clinical manifestations

  22. Symptoms of Gastric Disorders • Heartburn • Epigastric pain • Dyspepsia (upset stomach) • Vomiting • Hematemesis • Frequently “coffee-ground” emesis • Melena

  23. Physical Assessment • Advanced stage: • Nausea/vomiting • Obstructive symptoms • Iron deficiency/anemia • Palpable epigastric mass • Enlarged lymph nodes • Weakness/fatigue • Progressive weight loss

  24. DIAGNOSIS • Esophagogastroduodenoscopy - Polypoid mass - Ulcer crater - Thickened fibrotic gastric wall

  25. Preoperative evaluation • Abdominopelvic CT scan • Endoscopic ultrasonography • Chest CT • For patients with a proximal gastric cancer • PET scan • Sensitivity of PET scans for the detection of peritoneal carcinomatosis is only about 50 percent. • Staging laparoscopy • Between 20 and 30 % of patients who have disease that is beyond T1 stage on EUS will be found to have peritoneal metastases despite having a negative CT scan

  26. Gastric carcinoma

  27. Spread of Gastric Ca • Spreads through stomach into the gastric wall to the • Lymph nodes • Pancreas • Transverse colon • Omentum • Through portal vein into • Liver • Through systemic circulation into • lungs, and bone • Peritoneum • Ovaries • Pelvic cul-de-sac • Distant Lymph nodes

  28. Spread of Gastric Ca

  29. Clinical Presentation • Physical signs – advanced or mts • Palpable abdominal mass • Palpable supraclavicular (Virchow’s) LN • Palpable periumbilical (Sister Mary Joseph’s) LN • Peritoneal mets palpable by rectal exam (Blumer’s shelf) • Palpable ovarian mass (Krukenberg’s tumor) • Hepatomegaly

  30. Surgical Treatment • Absence of distant mts • Patient with distant mts but with complicated tumor • Line of resection at least 6 cm from the tumor mass to decrease recurrence at anastomosis

  31. Carcinoma of Stomach • Surgical options • Total gastrectomy Proximal tumours Mid-body tumours • Subtotal gastrectomy Distal tumours • Omentectomy

  32. Distal Tumors • Account for ~ 35 % of all gastric cancers • No 5-year survival difference b/n subtotal vs total gastrectomy • Subtotal appropriate if negative margins • Recurrence vs nonrecurrence depends on margin of 3.5 cm vs 6.5 cm margins 4 – 6 cm  10% involvement margins 2 cm  30 %

  33. Proximal Tumors • Cardia / proximal ~ 35-50% of gastric adenocarcinomas • Proximal • More advanced at presentation • Curative resection is rare • Total gastrectomy

  34. Palliation • 20 – 30% of gastric cancer presents as stage IV disease • Surgical palliation • Percutaneous, endoscopic, radiotherapuetic techniques • Nonoperative tx • Laser recanalization, endoscopic dilatation (+/- stent)

  35. Carcinoma of Stomach • Surgical treatment • Overall 5 year survival rate 10 – 21% in western series • Japanese series 50% • Adjuvant therapy (postoperative) • Neoadjuvant therapy (preoperative) Response rates vary from 21 –31% clinical response rate to complete response rate of 0-15%

  36. Adjuvant Therapy • Southwest Cancer Oncology Group trial • 5-FU, Leucovorin w/ chemorad for R0 • 3 yr survival 41% • Chem/Rad 3 yr survival 50% • 28% benefit in survival

  37. Gastric Carcinoma - Natural History • 2/3 of patients have locally advanced or metastatic disease at diagnosis • 50% recurrence following curative surgery • Adjuvant Chemo + R/T improves survival

  38. Recurrence • After gastrectomy quite high • 40 – 80 % • Most occur w/in first 3 years • Locoregional failure 38 – 45% • Anastomosis, gastric bed and regional nodes • Peritoneal dissemination – 54% • Annual endoscopy for subtotal gastrectomy

  39. Gastric Carcinoma • Prognosis • invasion is most important factor • early: limited to mucosa and submucosa; 90-95% survival at 5 years • late: beyond submucosa; less than 10 - 30% survival at 5 years • Five-year survival • 95 % for patients with superficial T1 tumors and negative lymph nodes (stage IA disease) • 7 - 8 % for patients with N3 nodes or any distant metastases • LN Dissection

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