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Adenocarcinoma of the

Stomach
SENG Jingjing M.D.
Department of General Surgery
Introduction
• Tumours of the stomach
Malignant ---great majority
Benign -------rare
Malignant tumours
primary

• Gastric carcinoma
• Lymphomas
• Carcinoid tumour
• Sarcoma
secondary

• Invasion from adjacent


tumours(pancreas or
colon)
Benign tumours
• Gastric polyps
• Leiomyomas
Gastric anatomy
• Cardia and pylori
• Fundus ,body, antrum
• Lesser curvature and
greater curvature
The Blood Supply of the
Stomach
• left gastric artery and vein
• right gastric artery and vein
• left gastroepiploic artery and vein
• right gastroepiploic artery and vein
• Short gastric artery and vein
EPIDEMIOLOGY
• Gastric cancer is the
second most
common cancer in
the world ,surpassed
only by lung cancer.
• Cancer of the
stomach is rare
before the age of 50
and increases in
frequency thereafter.
• Males have one and a
half times the risk of
females.
• The disease is more
common in low
socio-economic
groups.
Death Rate
• Costa rica
• Russia
• Japan
• Chile
• England
• Canada
• United states
RELATED FACTORS
• Environmental factors
• Diet
• Helicobacter pylori and chronic gastritis
• Adenomatous polyps
• Previous gastric operation
• Other
Environmental Factors
• The incidence of gastric
cancer varies from
country to country as
well as regionally within
countries.
• Studies of migrants from
Japan to the United States
,the offspring appear to
have the same risk as other
Americans.
• In much of the western
world, the incidence and
death rates have
steadily decreased in
recent years.
• It suggests that
environmental factors
play an important role.
Diet
• Gastric cancer appears to
be correlated with a high
intake of preserved foods,
(such as foods containing
high levels of
salt,nitrates,and
nitrites ),pickled
vegetables ,and salt
• Ascorbic acid and beta-
carotene in fresh fruits and
vegetables act as
antioxidants.---------Benefit
foods ,they can decrease the
incidence of gastric cancer.
Helicobacter Pylori and
Chronic Gastritis
• There is growing
evidence that HP
infection plays a role in
the development of
gastric cancer.
• The link between HP and
gastric cancer is
strengthened by the fact
that HP infection causes
more than 80% of chronic
gastritis cases.
• In addition ,chronic HP
infection, if untreated ,
usually leads to chronic
atrophic gastritis with
metaplasia ,with an
associated high risk of
gastric cancer.
Adenomatous Polyps
• Adenomatous gastric
polyps are rare but
carry a distinct potential
for the development of
malignancy.
• Patients with multiple
polyposis or multiple
recurrent adenomas
should be considered
for subtotal or total
gastrectomy.
Previous Gastric
Operation
• There is considerable
evidence that gastric
surgery for benign
conditions increases the
risk of gastric cancer by
twofold to sixfold.
• Most cases have
occured after Billroth 2
anastomosis ,15 to 20
years after the original
surgical procedure.
Molecular Genetics
• The molecular and
chromosomal alterations
leading to the development
of gastric adenocarcinoma
• Blood group A
• Hereditary non-polyposis
colon cancer syndrome
(HNPCC) ,associated with
an increased incidence of
gastric as well as colon
cancer
Pathology
• Microscopic
appearances
In 1965, Lauren divided
gastric cancers into
intestinal and diffuse
subtypes.
Pathology
• This classification is still
used internationally and
has prognositic
importance
Lauren’s Type
• Intestinal type• Diffuse type
Cells grow in Cells are singular
clumps and has and arranged in
histological files and are
features similar surrounded by a
to intestinal marked stromal
epithelium. reaction.
Macroscopic Pathology
• In 1926, Borrman
proposed a gross
classification of
gastric cancer .
• The system is still used
descriptively in the United
Stated and is a more
formal component of
tumor staging in Japan.
Borrman’s
Classification
• Group 1 circumscribed
,solitary ,polypoid
carcinomas without
ulceration
Borrman’s
Classification
• Group 2 ulcerated
carcinomas with wall-
like marginal elevation
and sharply defined
borders
Borrman’s
Classification
• Group 3 partially
ulcerated carcinomas
with marginal elevation
and partial diffuse
spread
Borrman’s
Classification
• Group 4 diffuse
carcinoma
Morphological forms
• Fungating tumours
• Malignant ulcers
• Infiltrating
carcinomas
• Linitis plastica
the leather-bottle
stomach
• Infiltrating carcinomas
spreads widely beneath the
mucosa and diffusely invades
the muscular wall,this causes
marked wall thickening and
rigidity and the whole
stomach contracts to a very
small capacity ,and its
appearance is likened to a
leather bottle.
Staging
• TNM Classification
Early Gastric Cancer
Early gastric cancer is defined as
disease involving the mucosa
or submucosa,and as such may
be fairly large .
Advanced Gastric
Cancer
• Advanced gastric cancer
suggests invasion of the
muscularis or beyond.
Symptoms and
Diagnosis
Symptoms are minimal until
late in the course of the
disease and patients most
commonly present with
advanced local and distant
disease
• Symptoms may be
produced by the local
effects of the tumour
,by secondary deposits
or by the general
features of malignant
disease.
Local symptoms
• Epigastric pain
• Pain radiating into the
back(suggesting
pancreatic
involvement)
Local symptoms
• Vomiting,especially with a
pyloric or antral tumour
producing pyloric obstruction
• Dysphagia in tumours of the
cardia
Symptoms from
secondaries
• The patient may first report
with jaundice due to liver
involvement or abdominal
distension due to ascites
General features
Examination

• Local examination :
a mass in the upper
abdomen
• A search for secondaries
:
enlargement of the liver
Virchow node
palpable mass on pelvic
examination
Virchow’s node

Enlarged ,hard left


supraclavicular nodes
Invasion and
Metastasis
• Direct spread
• Lymph node metastasis
• Blood duct metastasis
• Plant metastasis
Direct spread
Local spread is often well beyond the
naked-eye limits of the tumour and
the oesophagus or the first part of the
duodenum may be
infiltrated.Adjacent organs
(pancreas,abdominal
wall,liver,transverse mesocolon and
transverse colon )may be directly
invaded.A gastrocolic fistula may
develop.
Lymphatic
• Lymph nodes along the lesser and
greater curves are commonly
involved.Lymph drainage from the
cardiac end of the stomach may
invade the mediastinal nodes and
thence the supraclavicular nodes of
Virchow on the left side .at the pyloric
end ,involvement of the subpyloric
and hepatic nodes may occur.
Blood stream

• Dissemination occurs via


the portal vein to the liver
and thence occasionally to
the lungs and the skeletal
system.
Trans-coelomic spread

• May produce peritoneal


seedlings and bilateral
Krukenberg Tumours due
to implantation in both
ovaries.
Krukenberg tumour
• Gastric cancer
sometimes spreads
across the peritoneal
cavity, particularly to the
surface of the ovaries
Investigation
• Barium meal
• Endoscopy and
biopsy
• CT scanning
• For metastatic disease,
CT scanning is used
most widely to assess
the site and extent of
metastases before
embarking upon surgery
• It is useful for
showing local
tumour invasion ,
lymph node
involvement and
heptic metastase.
Differential diagnosis

• Carcinoma of the caecum


• Carcinoma of the
pancreas
• Pernicious anaemia
• uraemia
Treatment
• Radical surgery offers
the only prospect of
cure even when the
tumor is small.
Treatment
• The cure rate is
determined by the
stage of the disease
at presentation.
Survival Rate
• Survival results strongly
support the view that
early detection
dramatically increases
the chance of curative
surgery.
Radical gastrectomy
• Early • Advanced
cancer cancer
5-year 5-year
survival survival
90% <50%
Radical gastrectomy
• Tumour
• Resection margin:4-6cm
• Lymph nodes :R0-R4
resection
Adjuvant therapy
• Radiotherapy
• Chemotherapy
Summary
• Gastric cancer remains
a devastating disease.
• The 5-year survival in
patients with resection
of all gross disease and
clear margins ranged
from 20-38%.
Summary

• The extended resection


(R2)can be performed
safely.
Thanks