Gastric Carcinoma

3R

Epidemiology Risk Factor Clinical features Sites Pathology/Classification Spread Staging Prognosis Investigations Treatment

◦ Operation◦ Complication◦ Palliative◦ Chemo And Radiotherapy

References

Content

Rare before 50- increase thereafter Males > female 1.5:1 >lower socio economic More on Japan

Epidemiology

Predisposing

• Pernicious anaemia, atrophic gastritis

• Previous gastric resection

• Chronic peptic ulcer

Environmental

• H. pylori infection

• Smoking• Drinking • Low

socioeconomic status

Genetic

• Blood group A• Hereditary

non-polyposis colon CA

Risk factor

At early stage-minimal Dyspepsia *gastric antisecretory agents will improve

gastric cancer symptoms Depends on the location-proximal, body,

distal Advanced-early satiety, bloating, distention

and vomiting, IDA(bleed) LOA, LOW

Clinical features

Trousseau’s sign (thrombophlebitis) DVT Jaundice Cachexic Troisier's sign (palpable Virchow's node) Pelvic mass (metastases to ovaries)-

Krukenberg Tumor , Sister Joseph’s nodule

Clinical features

Site

Classification:◦ Lauren◦ Borrmann◦ Japanese

Lauren◦ Intestinal gastric cancer

Polypoid tumor or ulcers◦ Diffuse gastric cancer (worse prognosis)

Infiltrating, spread widely in gastric wall without obvious mass

◦ mixed

Pathology

Early-limited to mucosa and submucosa (T1, any N) curable

Japanese Classification

polypoidelevated

depressed

excavated

flat

Advanced-involved muscularis Type III and IV-incurable

Bormann Classification

polypoid fungating

ulcerated Diffusely infiltrative

Direct◦ Muscularis, serosa◦ Adjacent organ: pancreas, colon, liver

Lymphatic◦ Regional◦ Extensive- Left supraclavicular node

Blood◦ Via portal vein◦ Lung and bone

Transperitoneal◦ Indicates incurability◦ Anywhere in peritoneal cavity◦ Can give rise to ascites◦ Krukenberg tumor, Sister Joseph’s nodule

Spread

Staging

The 5-year survival rates by stage for stomach cancer treated with surgery are as follows:

Prognosis

Stage 5 yearobservedsurvival

Stage IA 71%

Stage IB 57%

Stage IIA 46%

Stage IIB 33%

Stage IIIA 20%

Stage IIIB 14%

Stage IIIC 9%

Stage IV 4%

OGDS, biopsy◦ Benign vs. malignant gastric ulcer

Loss of convergence of mucosal fold towards ulcer Everted instead of punch out

Investigations

Barium meal◦ Irregular filling defect, delayed emptying,

distorted outline of stomach

STAGING US Abd-liver mets, ascites, Krukenberg. LFT-liver mets CXR-lung mets CT TAP

Investigations

Curative resection not possible if:◦ Hematogenous spread present◦ Involvement of distant peritoneum◦ N3 or beyond N3◦ Fixation to structures that can’t be removed◦ Troisier’s sign +ve

Operability

With Roux-en-Y esophagojejunostomy

Total gastrectomy

Proximal stomach is preserved For tumor distally placed Billroth-II/polya

Subtotal gastrectomy

Leakage ◦ Anastomosis site◦ Duodenal stump (due to distal obstruction)

Biliary peritonitis Fistula from the wound or drain site

Post operative complication

Dumping-fainting, vertigo, sweating after food-osmotic effect high osmolarity of gastric content, reduce circulating volume

Nutritional deficiencies Early satiety steatorrhea Anaemia

◦ Vitamin B12(loss of parietal mass)◦ Iron (HCL)

Long term complication

Mostly chemotherapy Surgery-if obstructed Depend on the location of obstruction

◦ Pyloric end Tanner’s anterior gastrojejunostomy

◦ Cardiac end Stent

◦ Ultimately inoperable (linnitus plastica) Feeding jejunostomy

Palliative

Neo adjuvant chemo After curative surgery, chemotherapy is

recommended if there is LN/muscle/serosa involvement.

FEC-(5FU, epirubicin, cisplastin) Radiotherapy-role in painful bony mets.

Chemotherapy and Radiotherapy

Bailey & Love's Short Practice of Surgery 26E

H.George Burkitt and Clive Quick. ‘Essential surgery problems, diagnosis & management’, 4th edition, 2007

Harold Ellis and Roy York Calne. ‘Lecture note on general surgery’ , 12th edition, 2010

Guides on clinical surgery, AP Dr. Diganta Kumar Das et. al

American Cancer Society http://www.cancer.org/cancer/stomachcancer/detailedguide/stomach-cancer-survival-rates

References