THE GASTRIC

CARCINOMA
Prof. Faisal Ghani Siddiqui
FCPS; PGDip-bioethics; MCPS-HPE
Preamble
Epidemiology
Aetiologic factors
Pathology
Clinical features
Investigations
Treatment
Adenocarcinoma -Epidemiology
Incidence in USA/western Europe
Leading cause of death in Asia/Eastern Europe
Elderly
Blacks
Low SE status

What causes
Gastric Cancer?


Gastric Cancer
Pernicious anaemia
Blood group A
Family history of gastric cancer


Gastric Cancer
Diet

High fat diet
Pickled, preserved food
Tobacco
Fresh fruit and vegetables
Vitamin C
Regular aspirin





Gastric Cancer
Genetic Mutations
Deletion or suppression of p53
Overexpression of COX-2
CDH1


Gastric Cancer
Pre-malignant Conditions
Polyps
Atrophic gastritis
Benign gastric ulcer
Gastric ramnant
H.Pylori infection
Superficial gastritis
Atrophic gastritis
Intestinal metaplasia
Dysplasia
Cancer

Gastric Cancer
Pathology


Malignant Neoplasms of the
Stomach
Primary
Adenocarcinoma (94%)
Lymphoma (4%)
Malignant GIST (1%)
Haematogenous spread
Breast
Malignant melanoma
Direct invasion
Pancreas; Liver; colon; ovary
Gastric Cancer
Gross Appearance
Polypoid
Fungating
Ulcerative
Scirrhous
Gastric Cancer
Histology Lauren Classification
Intestinal
Diffuse
Unclassified
Gastric Cancer
TNM staging
Tis Intaepithelial tumour
T1 Tumour invades LP or submucosa
T2 Tumour invades muscularis propria or subserosa
T3 Tumour penetrates serosa without invasion of
adjacent structures
T4 Tumour invades adjacent structures
Gastric Cancer
TNM staging
N0 No regional lymph node metastases
N1 Metastasis in 1 to 6 regional lymph nodes
N2 Metastasis in 7 to 15 regional lymph nodes
N3 Metastasis in more than 15 regional lymph nodes
Gastric Cancer
TNM staging
M0 No distant metastasis
M1 Distant metastasis

Gastric Cancer
Clinical Manifestations


Symptoms
Weight loss
Decreased food intake
Abdominal pain
Nausea, vomiting and bloating
Acute GI bleeding
Chronic GI bleeding
Dysphagia
Trousseaus syndrome
(thrombophlebitis)
Acanthosis
Nigracans
Clinical Signs
Cervical, supraclavicular and axillary
lymphadenopathy
Pleural effusion
Aspiration pneumonitis
Abdominal mass
Sister Josephs nodule
Ascites
Rectal shelf of Blumer


Rudolph Virchow

Gastric Cancer
Diagnostic Evaluation


Prompt
upper endoscopy if
New onset of dyspepsia >45 years
Dyspepsia with alarm symptoms
(weight loss, anaemia, recurrent
vomiting, bleeding)
Dyspepsia & family h/o gastric
carcinoma
Preoperative Staging
Abdominal / pelvic CT scanning
Endoscopic ultrasound (EUS)
Depth of the tumour
Enlarged perigastric/coeliac lymph nodes

Gastric Cancer
Treatment


Surgical Resection &
Adequate Lymphadenectomy
is the only curative treatment
except
Metastases
Co-morbid
Surgical Resection
Resection of tumour
Grossly negative margin of at least 5 cms
Partial gastrectomy
Confirmed on frozen section
En block resection of adjacent involved
organs
Extent of Gastrectomy
Radical subtotal gastrectomy
(Distal tumour)

Total gastrectomy
(Proximal tumour)
Lymphadenectomy
D1: stations 3-6
D2: stations 1,2, 7,8 and 11
D3: stations 9, 10 and 12
Survival benefit to
adjuvant radio-chemotherapy
is marginal in patients who have undergone
adequate resection
In gross unresectable, metastatic tumour
Role of palliative
chemotherapy
is uncertain