stomach cancer

1. GASTRIC CARCINOMA
Dr.Avinash DNB Resident (gen .surg)

3. • Cardia :the first portion (closest to oesophagus )
• Fundus :the upper part of somach next to cardia .
• Body : the main part of stomach between upper
and lower parts .
• Antrum : lower portion where food is mixed with
gastric juices .
• Pylorus :the part which acts as a valve to control
gastric emptying .

4. • The first three parts are also called as proximal
stomach .
• This region has secretive cells which secret
gastric enzymes like pepsin .
• They also make a protein called castle
intrensic factor which the body needs to
absorb vitamin b12 .

5. • The lower 2 parts are called the distal stomach
.
• The stomach has 2 curves which form its inner
and outer borders .they are called the lesser
curvature and greater curvature respectively .

6. Blood supply of stomach
• Most of the blood supply to the stomach is from
• Four main arteries :
• Left gastric artery a branch of celiac trunk and right
gastric artery a branch of hepatic artery along the
lesser curvature .
• The right gastro epipolic artery branch of
gastrodeodenal artery and
• left gastro epiploic artery is a branch of splenic artery
along the greater curvature .
• Blood supply to the proximal stomach comes from the
inferior phrenic and short gastric arteries .

8. Venous drainage parallels the arterial
supply
• Left and right gastric veins drain into the
portal vein
• Right gastroepiploic drains into the SMV
• Left gastroepiploic drains into the splenic vein

9. Lymphatic drainage is into four zones:
• Superior gastric
• Suprapyloric
• Pancreaticolienal
• Inferior gastric/subpyloric
• All four drain into the celiac group of nodes
and into the thoracic duct.
• Gastric cancers drain into any of these groups .

11. • Innervation:
• Parasympathetic via the vagus.[left anterior
and right posterior.]
• Sympathetic via the celiac plexus.

12. Layers of stomach

13. • The layers are important in determining the
stage (extent) of the cancer and in helping to
determine a person’s prognosis (outlook).
• As a cancer grows from the mucosa into
deeper layers, the stage becomes more
advanced and the prognosis is not as good.

14. Etiological factors Predisposing
• low fat diet or protein diet .
• Salted meat or fish .
• High nitrate diet .
• High complex carbohydrate diet .
• Smoked foods .
• Poor refridgeration .
• Contaminated well water .
• Prior gastric surgery
• H pylori associated with PUD .
• GASTRITIS .
• Gastric atropy .
• Adenomatous polyps .
• Le fraumeni syndrome p53 mutation .
• E cadherin mutation .

15. Clinical Presentation
• Most patients present with advanced stage
because there are no early specific signs and
symptoms. Time lag between onset of disease
and onset of symptoms.
• Common clinical Presentation: 3A”s:
1.Anaemia(due to bleeding from tumour)
2.Asthenia(septic absorption from the
tumour)
3.Anorexia

16. • Recent onset of early satiety, dyspepsia,
epigastric discomfort.
• Specific symptoms depending on the site of
tumour.
• Tumour in pyloric region may present with gastric
outlet obstruction.
• Tumour in proximal region may present with
dysphagia,hamaetemesis.
• From the body of stomach may present as only
mass per abdomen(silent variety).

17. • Metastatic disease may present with-
jaundice,ascites.

18. Signs
• Grossly Anemic,
• Cachexia
• Epigastric mass
• liver secondaries
• Blumer shelf seondaries.
• Virchows node
• Sister mary joseph node
• Krukenberg tumor
• Irish node

19. BORRMANNS CLASSIFICATION
• Morphology:
• Polypoid
• Ulcerative
• Superficial spreading
• Infitrative [Linitis plastica, Leather bottle
stomach)

21. 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

23. SPREAD OF CARCINOMA STOMACH
DIRECT SPREAD .
LYMPHATIC SPREAD.
BLOOD BORNE SPREAD .
TRANSPERITONEAL SPREAD .

24. FOR TNM STAGING
• Upper gastrointestinal (GI) tract endoscopy and biopsy
• Chest/abdomen/pelvic computed tomography (CT) with oral and
intravenous contrast
• Positron emission tomography (PET) – CT evaluation if no evidence
of M1 disease is found, and if clinically indicated
• Complete blood cell count (CBC) and comprehensive chemistry
profile
• Endoscopic ultrasound if no evidence of M1 disease is found
• Endoscopic resection for early-stage cancers
• Biopsy of metastatic disease as clinically indicated
• HER2-neu testing if metastatic adenocarcinoma is documented or
suspected

25. Staging of gastric cancer
• TX - Primary tumor cannot be assessed
• T0 - No evidence of primary tumor
• Tis - Carcinoma in situ, intraepithelial tumor without invasion of lamina
propria
• T1 - Tumor invades lamina propria, muscularis mucosae, or submucosa
• T1a - Tumor invades lamina propria or muscularis mucosae
• T1b - Tumor invades submucosa
• T2 - Tumor invades muscularis propria
• T3 - Tumor penetrates subserosal connective tissue without invasion of
visceral peritoneum or adjacent structures
• T4 - Tumor invades serosa (visceral peritoneum) or adjacent structures
• T4a - Tumor invades serosa (visceral peritoneum)
• T4b - Tumor invades adjacent structures/organs .

26. Regional lymph nodes (N)
• NX - Regional lymph node(s) cannot be assessed
• N0 - No regional lymph node metastases
• N1 - Metastases in 1-2 regional lymph nodes
• N2 - Metastases in 3-6 regional lymph nodes
• N3 - Metastases in 7 or more regional lymph
nodes
• N3a - Metastases in 7-15 regional lymph nodes
• N3b - Metastases in 16 or more regional lymph
nodes
• Distant metastasis

27. METASTASIS
• M0 - No distant metastasis
• M1 - Distant metastasis

30. INVESTIGATIONS
• Full blood count
• LFT,RFT,
• Stool examination for occult blood,
• CXR.
• Serum tumor markers (CA 72-4,CEA,CA19- 9)

31. • UGI endoscopy with biopsy,
• ENDOSCOPIC ULTRASOUND ,CT, MRI & US .
• Diagnosic Laparoscopy
• Upper gastro intestinal endoscopy. Diagnostic
accuracy is 98% if upto 7 biopsies is taken.
Diagnostic study of Choice

32. • Management :
• Surgery
• Chemotherapy
• Radiotherapy

33. • TreatmentTreatment Initial treatment:
1.Improve nutrition if needed by parentral or
enteral feeding. 2.Correct fluid &electrolyte &
anemia if they are present.
• Preoperative Care Preoperative Staging is
important because we don’t want to subject
the patient to radical surgery that can’t help
him.

34. • D” Nomenclature describes extent of resection
and lymphadenectomy.
• D1 :removes all nodes within 3cm of tumor.
• D2: D1 plus hepatic, splenic, celiac, and left
gastric nodes.
• D3: D2 plus omentectomy, splenectomy, distal
pancreatectomy, clearance of porta hepatis
nodes.
• Current standards include a D1 dissection only.

36. • Multidisciplinary treatment planning before
any treatment decision is mandatory. The core
membership of the multidisciplinary team
should include
• surgeons, medical and radiation oncologists,
radiologists and pathologists, with other
members as available

37. Stage 0 to IA
• For early gastric cancer consider EMR and ESD
• Endoscopic mucosal ressection and endoscopic
submucosal dissection .
• GUIDELINES FOR EMR OR ESD:
• 1.Tumor limited to mucosa .
• 2.No lymphovascular invasion .
• 3.Tumor smaller than 2 cms .
• 4.No ulceration .
• 5.Well or modeately well differentiated
histopathology .

38. 3 .TYPES OF SURGERIES(Stage IB to
IIIC, potentially resectable)
• TOTAL GASTRECTOMY +ROUX en
oesophagojejunostomy
• SUB TOTAL GASTRECTOMY
• PALLIATIVE GASTRECTOMY

39. TOTAL GASTRECTOMY +ROUX en
oesophagojejunostomy
- For proximal lesions of funds or cardia this
method is used .
- Remove the stomach +distal part of
esophagus+ proximal part of duodenum +
greater & lesser omentum + LNs
Oesophagojejunostomy with roux-en-y .

41. SUB TOTAL GASTRECTOMY
• For tumors that are in distal part of stomach that
is body and antrum this method is used .
• The proximal stomach is transected at the level of
insisura at a margin of at least 6 cm because
studies have documented tumor spread as far as
5 cms .
• Similar to total one except that the PROXIMAL
PART of the stomach is preserved Followed by
reconstruction & creating anastomosis ( by
gastrojejunostomy,billroth II )

43. 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)

44. Post-Operative Complications
• 1.Leakage from duodenal stump.
• 2.Secondary hemorrhage.
• 3.Nutritional deficiency in long term.

45. Neoadjuvant Chemotherapy Regimens
• Preferred regimens:
• Paclitaxel + carboplatin .
• Cisplatin + 5 FU .
• Capecitabine + cisplatin .

46. Perioperative Chemotherapy Regimens
• "ECF" regimen : epirubicin , cisplatin , 5FU .
• "FLOT" regimen: 5 FU,FOLINIC ACID ,oxiplatin
,docetaxel .

47. Stage IV
• For HER2-NEU overexpressing
adenocarcinomas, trastuzumab should be
added to first-line chemotherapy

48. • Thank you !!