Ca Stomach

Dr Shafiq Chughtai
Resident Surgeon
SU II , Holy Family Hospital
Rawalpindi
ortho79@gmail.com
Incidence

 Men > Women , 2:1

 USA 10 ,UK 15 , Europe 40 ,

Japan 70 per 100,000 population.

 Marked variation world wide indicates a

strong environmental factor in this
disease.
Contd.
 6th commonest cause of cancer deaths
world wide.3rd GI malignancy after
pancrease and colorectal Ca.
 Incidence falling at 1% per year—dropped
to 1/3 in past 30 yrs
 Carcinoma of body & distal stomach
decreasing.
 Gastro-esophageal junction increasing.
Cancer in upper GI tract
Aetiology (Intestinal type)
 Pelayo-Correa model.
Underlying mechanism for these histological
changes are the genetic mutations
involving :

 p53.
 RAS oncogene.
 HER/neu gene.
Risk Factors
1 Diet Spiced , salted , pickled food , BBQ food
,animal fat consumptions , nitrates
consumption , protien malnutrition and
alcohal.
2 Infections H-pylori , viral infections

3 Congenital HNPCC , Familial adenomatous polyposis,

Blood group A.

4 Others Partial gastrectomy , atrophic gastritis ,

pernicious anemia , gastric polyp.
Pathology
Finnish / DIO /Lauren Classification

 Intestinal gastric cancer

 Diffuse gastric cancer

Intestinal gastric cancer
 Origin from areas of gastric metaplasia.

 Early cancer remains localized forming

large localized masses , metastasis is late.

 More common in elderly & males.

 Better prognosis.
Diffuse gastric cancer
 Arise from normal gastric mucosa.

 Cells lack cohesion spread diffusely in stomach

wall without forming localized masses and with
early metastasis.e.g linitis plastica

 Young and female.

 Worse prognosis.
Types of gastric cancer

 (I) Histology.

 (II) Macroscopic appearance.

 (III) Extent of spread.

(I) Histological subtypes of gastric
cancer
 Adenocarcinoma 95%

 Primary Gastric Lymphoma 4%

 Masenchymal tumors 1%
(II) Macroscopic appearence

 Intraluminal (polypoid and fungating)

 Intramural (ulcerative or scirrhus )

(III) Extent of spread

 Early gastric cancer

 Late gastric cancer

 Early gastric cancer is when cancer
involve the mucosa or submucosa
irrespective of nodal involvement

 Advanced gastric cancer is when the

cancer involves the muscularis propria
Early gastric cancer
Japanese classification
Advanced Gastric Cancer
Borrmann classification
Contd.

 Type 3 and 4 carry the worst prognosis.

Spread

 Direct spread

 Lymphatic spread

 Blood borne metastasis

 Trans peritoneal spread

Direct spread

Depending upon the location

 Esophagus
 Lesser and greater omentum
 Liver and pancrease
 spleen
 Transverse colon
Lymphatic spread
Blood Borne Spread

 Lungs

 Liver

 Bones
Trans peritoneal (P)

 Extensive involvement means incurablity.

 Blummer shelf / drop metastasis

 Krukenberg tumor , Sister Joseph nodule.

Staging
TNM classification

T1 Mucosa and submucosa

T2 Muscularis propia

T3 Serosa

T4 Surrounding structures
Nodes
N0 No metastasis to reginal lymph nodes

N1 Nodal metastasis (perigastric) within

3 cm of primary tumor

N2 Nodal metastasis >3 cm from primary

tumor
Metastasis
M0 No metastasis

M1 Distinct metastasis
TNM Staging
Clinical features

Early symptoms

Late symptoms
Early symptoms

 Non specific & mimic APD

 Dyspepsia , indigestion , post parindial

fullness , maliase

 Will respond to PPI’s and H2 blockers.

Late symptoms

 Anorexia & Weight loss.

 Dysphagia ---cardia involvement

 Vomiting----due to gastric outlet

obstruction.
contd
Contd.

 Anemia ---iron deficency type , ch.blood

loss (30%).

 Heamatemeisis and malena----acute bleed

from malignant ulcer.
Signs

 GPE---wasting , pallor , jauindice

 Neck---virchow node , trosiers sign

 Chest---basal consolidation / pl.effusion ,

Mets.
contd.
Contd.
Abdomen

Malignant ascites ,

Hepatomegally.
Mass epigastrium , visible peristalasis .

Succusion splash,

DRE / Pelvic Mass on examination

(krukenberg / drop metastasis)
Investigation
 Blood CP – Anemia

 CXR

 LFT’s and albumin

 Electrolytes (hypochaloremic metabolic

alkalosis)
 Cardiac and Pulmunary status of the
patient should be assessed.

 Echo , ECG , PFT’s .

Investigations

Upper GI Endoscopy

 Direct inspection (Site & extent )

 Multiple biopsies for tissue diagnosis

Imaging Studies
Barium Meal Examination :
 Less commonly performed nowadays
 Useful in diagnosis of:
 large primary tumors
 Irregular strictures
 Linitis plastica (leather bottle stomach)
Double-contrast upper GI series
 Can detect smaller primary lesion
Imaging Studies

Endoscopic ultrasound
 preoperative assessment of
“ T stage ” , Sm superficial / deep.

CT / MRI
 May show nodal & metastatic spread:
 “ N stage ” & “ M stage ”
 Influences type of surgical treatment
T3 N0 OR T3 N1 = II or III A.
Imaging Studies

Chest Radiograph
 Mets into lungs , effusion or basal
consolidation .

Abdominal Ultrasound
 Mets into liver, ascites .
Serology

 CA 724 is the only reliable tumor marker.

 CEA has specificity of 65%

Laproscopy

 Assess operablity and rule out fixity to

adjuscent structures.

 Staging for peritoneal Mets (only reliable

mode) .
Traetment of early gastric cancer

 Aim –achieve 2cm clear tumor free

margins

 Tumor less then 3 cm ---local resection

 Tumor more then 3 cm or type IIa/IIc, D1

clearence to be done.
Treatment of late gastric cancer

 Aim---achieve 5cm tumor free clear

margins.

 Three steps , gastric resection , nodal

clearance and reconstruction.
Nodal clearence

 Principle---clearence of one tier of lymph

nodes above the one which are
macroscopically involved.

 D1 D2 D3
D1 Clearence

 Confined to primary group of nodes mainly

along lesser and greater curvature , rt and
lt cardiac nodes , juxtapyloric nodes.

 Removal of greater and lesser omentum

with excised stomach.
contd.
D1
D2 clearence

 D1 + cealaic nodes and the nodes along

its branches namely Lt gastric , hepatic
and splenic nodes.Nodes in splenic hilum
and retropancreatic nodes removed.

 May need splenectomy and resection of

body and tail of pancrease.
D2
D3 clearence

 D1+D2+nodes of porta hepatis , behind

pancreatic head , in root of mesentry ,
along the middle colic and paraaortic
nodes.

 May involve partial colectomy , hepatic

lobectomy , subtotal pancreatectomy ,
pancreatico duodenectomy.
D3
Gastric resection

 (I)Total gastrectomy

 (II)Subtotal gastrectomy

 (III)Esophagogastrectomy
(I)Total gastrectomy

 Tumor involves 2 or all 3 zones of

stomach.
 Its diffuse & Bromann type IV , irrespective
of size.
 When proximal distance from the cardia is
less then required length to achieve safe
tumor free margins.
(II)Subtotal gastrectomy

 Done for tumors which are distally placed

in stomach.

 Proximal stomach is preserved with its

blood supply.
 Billroth I

Subtotal Hofmeister’s method

Gastrectomy

Polya’s method
Billroth II
Moynihan’s method

V.Eiselsberg’s method
(III)Esophagogastrectomy

 Done for tumors of cardia

 Reconstruction by intrathoracic
Esophagogastrostomy
 Principle of reconstruction

 After doing gastric resection ,

reconstruction is undertaken. If the primary
lesion is considered curative , duodenal
continuity is established.

 If the lesion is non curative duodenal by

pass surgery is done.
Curative resection
4 criterias

 No hepatic or peritoneal mets.

 No serosa involvement.
 Resection margins are free from tumor on
H/P exam.
 D resection exceeds level of nodal
involvement.
Curative resection

Aim --- to restore duodenal continuity

because of increased nutritional outcome.
 Total gastrectomy ---jejunal interposition
reservior
 Subtotal gastrectomy---gastroduodenal
anastomosis/bilroth-I
Total gastrectomy
jejunal interpositions
Subtotal gastrectomy
bilroth-I/GD anastomosis
Non curative excision

Aim In non curative excision , we do

duodenal bypass surgery because
gastroduodenal anastomosis has more
chances of obstruction if recurrance
occour.
 Total gastrectomy , do loop jejunostomy or
roux en Y loop.
 Subtotal gastrectomy polya / bilroth II
gastrectomy.
Total gastrectomy
loop Jej/Roux en Y Loop
Subtotal gastrectomy
Bill-II / Polya
Unresectable tumors
 Heamatogeneous spread .

 Peritoneal spread

 Fixity to adjuscent strs. That can not be

removed surgically
Palliative surgery

 Indications are unresectable tumor with

pain , vomiting , dysphagia , bleeding.
 Expanding metallic / plastic stents for
dysphagia if cardia is involved.

 Palliative gastrectomy if body / fundus is

involved.

 Teners antecolic gastrojejunostomy if

antral neoplasm.
Teners antecolic gastrojejunostomy
To summarize the Rx
Chemotherapy
Cunningham regimen

(ECF)
Epirubicin 50mg/m thrice weekly plus

Cisplatin 60 mg / m thrice weekly infusion

plus

5FU 200mg/m daily by hickman line.

Radiotherapy

 Radiotherapy has no defined role in

gastric malignancy.
 Prognosis

 Depends upon stage of the disease at the

time of treatment
 Early gastric carcinoma undergoing
curative resection
 50-70 % 5-year survival
 Advanced gastric carcinoma undergoing
resection
 5 % 5-year survival
 Mesenchymal tumors

 Smooth muscle –leiomyoma and

leiomyosarcoma

 Neurogenic---schwanoma

 Uncommitted mesenchymal cells or GIST.

Treatment

 Less then 5 cm –local resection with 1-2

cm clean margins.

 More then 5 cm ---local resection with

nodal clearence.
 Gastric Lymphomas

 All are Non Hodgkin’s type , rarely id

Hodgkin’s lymphoma seen in stomach.

 Diagnosis is by endoscopy and biopsy.

Staging
 STAGE-I Single lymphnode region.

 STAGE-II Two / more lymph node regions on

same side of diaphram

 STAGE-III Lymph nodes on both sides of

diaphram

 STAGE-IV Disseminated disease.

Treatment

 Stage I ---H pylori eradication.it will cure

the disease if the pt is +ve for it.Other wise
surgery is done.

 Stage II----gastrectomy with

chemotherapy.

 Stage III/IV chemotherapy.

Thank You .