Here I am discussing about Gastric Carcinoma under the problem Epoigastric Lump.

1. GASTRIC CARCINOMA
EPIGASTRIC LUMP
AN OVRVIEW
Dr.B.Selvaraj MS;Mch;FICS;
“Surgical Educator”
Malaysia

2. GASTRIC CARCINOMA
 Causes for Epigastric Lumps
 Epidemiology
 Risk factors
 Pathology
 Classifications
 Clinical Features
 Investigations
 Staging
 Treatment
 Prognosis
 Mindmap
 Treatment algorithm
OBJECTIVES

3. Causes For Epigastric Lumps
 Epigastric/Omental hernia
 Pancreatic tumor/Cyst including pseudocyst
 Gastric Carcinoma
 GIST- Gastro-Intestinal Stromal Tumors
 AAA- Abdominal Aortic Aneurysm
 Retroperitoneal Sarcoma
 Hepatomegaly

4. GASTRIC CARCINOMA
 Comprises 95% of all gastric tumors
 Fourth most common gastrointestinal (GI)
malignancy worldwide
 Second cause of cancer mortality worldwide
(behind lung cancer)
 Approximately 25,000 cases reported in
United States in 2015
Epidemiology
 Seventy percent of patients older than 50
(peak in seventh decade of life)
 Male to female ratio: 2:1
 Greatest incidence in Japan (80 times greater
than in the United States)
 Sixty-five percent of gastric cancers in the
United States present at an advanced stage
(T3/T4).

5. GASTRIC CARCINOMA
 Environmental factors:
- Diet rich in salt, smoked or poorly preserved
foods, nitrates, nitrosamines
- Smoking
- Low socioeconomic status
-Occupational hazards metal, rubber,wood and
asbestos industries
 Genetic Factors:
- 10% of Gastric Ca are familial/inherited;
90% are sporadic
-Syndromes associated with gastric carcinoma:
# BRCA1, BRCA2, HNPCC, FAP, Peutz-
Jeghers, Li-Fraumeni syndrome
- Blood group A
- Ethnicity common in Asians, Native and
African Americans, Latinos Vs Whites
Risk Factors
 Infectious factors:
- H.Pylori 6 to 8 times increased risk and
common in distal cancer
- Epstein-Barr virus
 Other factors:
- Chronic atrophic gastritis produced by
Pernicious anemia & Menetrier disease
- Gastric polyps: Risk of malignancy is
directly increased with increased size
and degree of dysplasia.
- Reflux gastritis after subtotal gastrectomy
# Risk with Billroth II >> Billroth I
reconstruction

6. GASTRIC CARCINOMA
 Sites & their frequency:
Pathology
 Histological types:
- Adeno, Adeno-squamous, Squamous, lymphoma &
leiomyosarcoma
 Spread:
- Local infiltration
-Haematogenous to liver, lung, brain;
-Transcoelomic to ovary (Krukenberg tumor)
- Lymphatic:
- Axillary node Irish nodes
-Lt supraclavicular node Virchow’s node
-Umbilical skin Sister Mary Joseph nodes
-Ovaries Krukenberg’s tumor
-Rectovesical pouch in men Blummer’s shelf

7. GASTRIC CARCINOMA
Classifications
Macroscopic:
a) Early: Japanese
classification
b) Advanced: Borrmann
classification
Microscopic: Lauren-Jarvi
classification
Japanese classification Borrmann classification

8. GASTRIC CARCINOMA
Classifications
Microscopic: Lauren-Jarvi classification

9. GASTRIC CARCINOMA
 It often produces no specific symptoms when it is
superficial and potentially curable.
 Up to 50% of patients may have nonspecific GI
complaints, such as dyspepsia.
 Other symptoms include abdominal pain,
nausea, vomiting, early satiety with bulky
tumors, dysphagia, hematemesis, and melena.
 Anemia
 Anorexia
 Asthenia
 Blood group A
 Proximal tumors dysphagia& achalasia like
symptoms
 Distal tumors dyspepsia & GOO
Clinical Features
Symptoms Signs
 This is unhelpful in early gastric cancer.
 Palpable abdominal mass, cachexia, bowel
obstruction, ascites, hepatomegaly, and lower
extremity edema are signs of advanced disease.
 Classic findings:
 Krukenberg’s tumor
 Irish nodes
 Sister Mary Joseph nodules
 Blummer’s shelf
 Virchow’s node
 If antral tumor with GOO Succussion splash

10. GASTRIC CARCINOMA
Investigations Upper GI Endoscopy
Endoscopic diagnostic criteria:
 No typical features. In some cases, the mucosa
appears almost normal, in others it appears
gastritic with patchy erythema and a bumpy
surface.
 Ulcerations: superficial or deep, with or without
raised edges, multiple, bizarre
 Polypoid growth is sometimes seen.
 Location: ubiquitous, with a predilection for the
gastric body and antrum

11. GASTRIC CARCINOMA
Investigations EUS- Endoscopic Ultrasound
Endoscopic ultrasound:
 Best investigation to stage any GI tumors
 5 layers of the gastric wall may be identified, and
the depth of the invasion can be assessed precisely
 Enlarged lymph nodes can also be assessed

12. GASTRIC CARCINOMA
Investigations CECT
CECT:
 Gastric wall thickening associated with a
carcinoma of any reasonable size can be easily
detected by CT but lacks sensitivity in detecting
smaller lesions.
 Less accurate in ‘T’ staging than endoluminal
ultrasound.
 Lymph node enlargement can be detected

13. GASTRIC CARCINOMA
Investigations CT-PET SCAN
CT-PET SCAN:
 PET is a functional imaging technique which
relies on the uptake of a tracer in most cases
by metabolically active tumour tissue.
 Fluorodeoxyglucose (FDG) is the most
commonly used tracer.
 Increasingly being used in the preoperative
staging of gastro-oesophageal cancer
 The middle pair of images shows the primary
tumour.
 The two images on the left show unsuspected
liver metastases
 Two on the right show a left cervical node
positive for metastases.

14. GASTRIC CARCINOMA
AJCC STAGING

15. GASTRIC CARCINOMA
Treatment
Classification Of final resections with respect to
final pathology
 R0—no residual tumor
 R1—microscopic residual disease only
 R2—gross residual disease
 Curative resection—macroscopic margin of 5–6 cm
is recommended together with lymphadenectomy.
Tumors in the proximal third of the stomach
 Total gastrectomy with reconstruction is preferred.
 Roux-en-y esophagojejunostomy is the
reconstruction
 Perform esophago-gastrectomy for tumors of the
gastroesophageal junction.
Tumors in the middle to distal third of the
stomach
 Distal subtotal gastrectomy is associated with
improved quality of life over total gastrectomy and
identical survival outcomes.
 A 5-cm margin in the proximal stomach is needed
Reconstruction
 Billroth I: need enough stomach for tension free
anastomosis
 Billroth II: single anastomosis, associated with
increased bile reflux,Barrett esophagus, marginal
ulcers, and duodenal stump leaks
 Roux-en-Y: preferred method for reconstruction
when Billroth I cannot be performed
 En bloc resection of spleen, liver, transverse colon,
and/or pancreas may be required for locally
advanced tumors.

16. GASTRIC CARCINOMA
Treatment
Lymphadenectomy:
 Minimum of 15 lymph nodes required for
adequate staging
 Benefit: better staging, improved locoregional
control, questionable survival benefit
 Nomenclature for extent of resection:
-D1—omental and peri-gastric lymph nodes
-Extended D1—omental and perigastric lymph
nodes plus lymph nodes along the left
gastric artery, common hepatic artery,
and celiac axis
-D2—extended D1 plus distal pancreatectomy
and splenectomy to harvest
peripancreatic and peri-splenic nodes
Palliative surgery—for obstruction or bleeding in
patients with unresectable tumors
 GI bypass—for patients who can tolerate a
laparotomy and are not candidates for gastric
resection
Endoscopic mucosal resection for early gastric cancer-
EMR
 Limited to experienced centers
 Incidence of lymph node metastasis in early gastric
cancer is less than 10%.
 Close endoscopic follow-up is necessary.
 Indications are nonulcerated tumors, ulcerated
tumors less than 3 cm, any tumor smaller than 3 cm,
and less than 0.5-mm invasion into submucosa.
 Contraindications: diffuse tumor, deep submucosal
invasion (>0.5 mm)

17. GASTRIC CARCINOMA
Treatment
NEOADJUVANT/ADJUVANT THERAPY :
 Perioperative chemotherapy
1. Three cycles of preoperative chemotherapy
2. Surgery followed by three additional cycles of
chemotherapy
3. MAGIC regimen = epirubicin, cisplatin, and
infused fluorouracil
4. Five-year survival rate of 36% versus 23%
(surgery alone)
 Adjuvant chemoradiation therapy
1. Postoperative 5-fluorouracil and leucovorin
and 45-Gy radiation
2. Overall 5-year survival 43% versus 28% in
`surgery alone
Adjuvant chemotherapy:
1. Six months of postoperative chemotherapy
(capecitabine an oxaliplatin)
2. Improved 5-year survival and recurrence rates
over surgery alone

18. GASTRIC CARCINOMA
Essential Treatment

19. GASTRIC CARCINOMA
Prognosis

20. GASTRIC CARCINOMA
Mindmap

21. GASTRIC CARCINOMA
Treatment Algorithm

22. Peripheral Arterial Diseases(PAD)