metastatic carcinoma of stoamch
DESCRIPTION
histopathology pptTRANSCRIPT
Metastatic Adenocarcinoma of Stomach
• Adenocarcinoma of the Stomach
• Definition
• Malignant gland forming neoplasm of the stomach, exclusive of the EGJ and gastric cardia
Gastric Cancer
Epidemiology
Forth common types of cancer
Second most common cancer related death
Geographic variations (ten times)
Continuing decline
Primarily a decline of distal GC
(2000) (2000)
Geographic variations
Gastric Cancer
Environmental factors
H. pylori Genetic factors
Etiological Factors of Gastric Cancer
Precancerous changes
The role of H. Pylori infection in gastric carcinogensis
Type I carcinogen1994 by IARC
Gastric Cancer
Attributable risk50%~73%
Epidemiological studie
Environmental factors
Environmental factors are involved
Japanese immigrants in US: 25%
Second generation: >50%
Subsequent generations: comparable to General US population
Environmental factors
Lower socioeconomic status
Tobacco/alcohol
Fresh vegetable/fruits/Micronutrition
Poor food storage
Eating salted/Smoked food
Mucosal damage
Pro-carcinogen/Carcinogen
Lack of antioxidant
GASTRIC CANCERC
Genetic factors
• The majority of gastric tumor are sporadic in nature
• There are rare inherited gastric cancer predisposition.
Precancerous changes
Precancerous lesions
Precancerous conditions
Precancerous lesions
• Defined as those pathological changes predisposed to
gastric cancer
dysplasia
• 10% of patients may progress in severity• majority of patients either regress or remain stable• High-grade dysplasia may be only a transient phase in the
progression to gastric cancer• occurs in atrophic gastritis or intestinal metaplasia
Nature history of gastric dysplasia
No
Dysplasia
No
DysplasiaMild
Dysplasia
Mild
Dysplasia
Moderate
Dysplasia
Moderate
Dysplasia
High-grade
Dysplasia
High-grade
Dysplasia
Gastric
adenocarcinoma
Gastric
adenocarcinoma
5 years5 years 5 years5 years
5 years5 years
3 months-2 years3 months-2 years
10%10%
10%10%
50%-90%50%-90%
60%60%60%60%
10%10%
Precancerous condition
• Defined as those clinical setting with higher risk of
developing gastric cancer
Chronic atrophic gastritis
Gastrectomy
Pernicious anemia
Menetrier’s disease
Chronic gastric ulcer
Gastric polyps
Postulated sequence of histologic events in the progression to gastric adenocarcinoma and potential contributory factors
H. PyloriH. Pylori Other factorsOther factors
Chronic Superficial Gastritis
Chronic Superficial Gastritis
Intestinal Metaplasia
Intestinal Metaplasia
Atrophic Gastritis
Atrophic Gastritis DysplasiaDysplasia
FAP or Adenomas
FAP or Adenomas
Gastric Adenocarcinoma
Gastric Adenocarcinoma
Other factorsOther factors
AssociationAssociation Strong Association
Strong Association
Pathology
Stages
Morphology
Pathohistologic classification
Metastasis
Stages
• Early stage limited in the mucosa and sub mucosa layers, no matter with or without lymph node metastasis Classified by the Japanese Society for Gastric Cancer <1cm <0.5cm
• Advanced stage invaded over sub mucosa According to Bormann’ classification
TNM classification (UICC)
0 Tis N0 M0 III A T2 N2 M0
I A T1 N0 M0 T3 N1 M0
I B T1 N1 M0 T4 N0 M0
T2 N0 M0 III B T3 N2 M0
II T1 N2 M0 IV T4 N2 M0
T2 N1 M0 T1~3 N3 M0
T3 N0 M0 any T any N M1
Morphology---Early stage
Morphology---Early stage
Morphology---Early stage
Morphology ---Advanced stage
Histopathological classification
Histology
Adenocarcinoma 90%
Lymphoma 5%
Stromal 2%
Carcinoid <1%
Metastasis <1%
Adenosquamous/squamous <1%
Miscellaneous <1%
Origin (Lauren)
• Intestinal type
associated with most environmental risk factors
carries a better prognosis
shows no familial history
• Diffuse type
consists of scattered cell clusters with poor prognosis
Growth pattern (Ming)
• Expanding type
grew en mass and by expansion
resulting in the formation of discrete tumor nodules
with relatively good prognosis
• Infiltrative type
invaded individually
with poor prognosis
Metastasis
Direct invasion
Lymph node dissemination
Blood spread
Intraperitoneal colonization
Special term
• Blumer shelf
A shelf palpable by rectal examination, due to metastatic
tumor cells gravitating from an abdominal cancer and
growing in the rectovesical or rectouterine pouch
• Krukenberg tumor
A tumor in the ovary by the spread of stomach cancer
Clinical manifestationSigns and Symptoms
Early Gastric Cancer
Asymptomatic or silent 80%
Peptic ulcer symptoms 10%
Nausea or vomiting 8%
Anorexia 8%
Early satiety 5%
Abdominal pain 2%
Gastrointestinal blood loss <2%
Weight loss <2%
Dysphagia <1%
Signs and Symptoms
Advanced Gastric Cancer
Weight loss 60%
Abdominal pain 50%
Nausea or vomiting 30%
Anorexia 30%
Dysphagia 25%
Gastrointestinal blood loss 20%
Early satiety 20%
Peptic ulcer symptoms 20%
Abdominal mass or fullness 5%
Asymptomatic or silent <5%
Duration of symptoms
Less than 3 month 40%
3-12 months 40%
Longer than 12 month 20%
Special signs & terms• Linitis plastica: diffusely infiltrating with a rigid stomach
• Virchow’s node: supraclavicular lymphadenopathy (left)
• Irish’s node: axillary lymphadenopathy
• Sister Mary Joseph’s node: umbilical lymphadenopathy
Sister Mary Joseph’s node
Laboratory tests
Iron deficiency anemia
Fecal occult blood test (FOBT)
Tumor markers (CEA, Ca19-9)
Diagnosis
Endoscopic diagnosis
--- biopsy needed for definitive diagnosis
Radiologic diagnosis
Detection of early gastric cancer
Endoscopic diagnosis
• In patients with signs and symptoms suggestive of
GC, and/or with compatible risk factors or paraneoplastic
conditions, the diagnostic procedure of choice could be
an endoscopic examination
• The diagnostic criteria for early or advanced gastric
cancer under endoscopy are based on the JRSGC and
Bormann’s classification
Endoscopic features of gastric cancer
Radiologic diagnosis • For reasons of cost and availability, radiography may sometimes be the first diagnostic procedure performed
• Classic radiography signs of malignant gastric ulcer
asymmetric/distorted ulcer crater
ulcer on the irregular mass
irregular/distorted mucosal folds
adjacent mucosa with obliterated /distorted area gastric
nodularity, mass effect, or loss of dispensability
Radiologic diagnosis
Distal GC Proximal GC Linitis plastica
Detection of early gastric cancer
• Endoscopic screening
general population or high risk persons
• Careful observation
Differential diagnosis
Gastric Cancer
Gastric Ulcer
Complications
• GI bleeding 5%
• Pylorus/cardia obstruction
• Perforation ulcer type
Treatment
Surgical resection
EMR
Adjuvant therapy
Palliative therapy
Endoscopic mucosal resection
Gastric cancer lesion confined to mucosa layer
Endoscopic ultrasound (EUS) is helpful in stageing GC
Endoscopic mucosal resection
Endoscopic mucosal resection
Chemotherapy Regimen Approximate Survival
Response rate BenefitFluorouracil +doxorubicin 30% No
+ mitomycin (FAM)
Fluorouracil + doxorubicin 30% No
Semustine (FAMe)
Fluorouracil + doxorubicin 30% No
+ cisplatin (FAP)
Etoposide + doxorubicin 40% No
+ cisplatin (EAP)
Etoposide + leucovorin 30% No
+ fluorouracil (ELF)
Fluorouracil +doxorubicin 40% Unconfirmed
+ methotrexate (FAMTX)
AIM OF COMBINATION THERAPYAIM OF COMBINATION THERAPY
INCREASED EFFICACYINCREASED EFFICACY
Different mechanisms of action Compatible side effects
Different mechanisms of resistance
ACTIVITYACTIVITY SAFETYSAFETY
Side effects of chemotherapySide effects of chemotherapy
Mucositis
Nausea/vomiting
Diarrhea
Cystitis
Sterility
Myalgia
Neuropathy
Alopecia
Pulmonary fibrosis
Cardiotoxicity
Local reaction
Renal failure
Myelosuppression
Phlebitis
Metal stent
Prognosis
• The TNM classification/staging of gastric cancer is the best prognostic indicator
• The 5 years survival rate depends on the depth of gastric cancer invasion
• Patients in whom tumors are resectable for cure also have good prognosis
Prevention
• Eradication of H. Pylori infection in those high risk
population family history of gastric cancer
chronic gastritis with apparent abnormality (atrophy, IM)
post early gastric cancer resection
gastric ulcer
• Management of dietary risk factor intake adequate amount of fruits, vegetables
minimize their intake of salty/smoked foods
Prevention
• Tightly follow up those with precancerous condition
• Endoscopic or radiologic screening