GASTRIC
CANCER
DONE BY : MUSTAFA KHALIL IBRAHIM
TBILISI STATE MEDICAL UNIVERSITY
4th year, 1st semester, 2nd group
ANATOMY & PHYSIOLOGY
ANATOM
Y stomach J-shaped.
The It has two surfaces (the anterior &
posterior), two curvatures (the greater & lesser), two orifices (the
cardia & pylorus). It has fundus, body and pyloric antrum.
Blood supply
The left gastric artery
Right gastric artery
Right gastro-epiploic artery
Left gastro-epiploic artery
Short gastric arteries
GASTRIC CANCER
Stomach cancer begins when cancer cells form in the
inner lining of your stomach. These cells can grow into a
tumor. Also called gastric cancer, the disease usually
grows slowly over many years.
It could be:
malignant or benign
primary or secondary
TYPES
Tumor Type Percent
Malignant tumors 93.0
Carcinoma 87.9
Lymphoma 3.0
Leiomyosarcoma 1.7
Carcinoid 0.3
Others 0.1
Benign tumors 7.0
Polyp 3.1
Leiom yoma 2.0
Inflammatory lesions 0.7
Heterotopic pancreas 0.4
Others 0.8
The four most common primary
malignant gastric neoplasms
are:
Adenocarcinoma (95%) : Cancer that begins in the
glandular cells.
Lymphoma (4%) : Cancer that begins in immune
system cells .
Carcinoid cancer(3%) : Cancer that begins in
hormone-producing cell.
Gastrointestinal stromal tumor (GIST) (1%) :
Cancer that begins in nervous system tissues of
stomach .
EARLY GASTRIC CANCER
Defined as a tumor confined to the mucosal or sub-mucosal
layer, with or without lymph node metastasis
ADVANCED GASTRIC CANCER
invasion depth beyond sub-mucosal
layer
BORMANN CLASSIFICATIONS
Gross classification
• phymatoid type
• ulcerative type
• infiltrative ulcerative
• diffuse infiltrative type
TNM
T: Primary tumor
Tis Carcinoma in situ; intraepithelial tumor without invasion of
lamina propria
T1 Tumor invades lamina propria or submucosa
T2 Tumor invades muscularis propria or subserosa
T3 Tumor penetrates serosa (visceral peritoneum) without
invasion of adjacent structures
T4 Clinical Manifestations Tumor invades adjacent structures
N: Regional lymph node
N0 No regional lymph node metastasis
N1 Metastasis in 1 to 6 regional lymph nodes
N2 Metastasis in 7 to 15 lymph nodes
N3 Metastasis in more than 15 regional lymph nodes
M: Distant metastasis
M0 No distant metastasis
M1 Distant metastasis
SPREAD PATTERNS
Direct invasion
Lymph node
dissemination
Blood spread
Intraperitoneal
colonization
ETIOLOGY
Gastric cancer is more common Stomach su rger y for a n ulcer
in patients with Epstein-Barr virus infection
pernicious anemia. Working in coal, metal,
blood group A. timber, or rubber industries
Exposure to asbestos
Gastric ulcer .
Infection with Helicobacter
A family history of pylori
gastric cancer. Long-term stomach
Smoking inflammation
Being overweight or
Had a polyp larger than 2
obese centimeters in your stomach
A diet high in smoked,
pickled, or salty
foods
SIGNS AND SYMOTOMS
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%
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%
SPECIAL SIGNS
Linitis plastica :
--- diffusely infiltrating with a rigid stomach
Virchow’s node :
--- left supraclavicular lymph node
Sister Mary Joseph’s node :
--- umbilical lymph node
prerectal pouch mass (Blumer shelf)
--- seeding metastasis
SISTER MARY JOSEPH’S NODE
COMPLICATIONS
Peritoneal and pleural effusion
Obstruction of gastric outlet or small bowel
Bleeding
Intrahepatc jaundice by hepatomegaly
STAGES OF GASTRIC CANCER
Stage I. At this stage, the tumor is limited to the layer of tissue
that lines the inside of the stomach. Cancer cells may also
have spread to a limited number of nearby lymph nodes.
Stage II. The cancer at this stage has spread deeper, growing
into the muscle layer of the stomach wall. Cancer may also have
spread to more of the lymph nodes.
Stage III. At this stage, the cancer may have grown through all
the layers of the stomach and spread to nearby structures. Or it
may be a smaller cancer that has spread more extensively to
the lymph nodes.
Stage IV. This stage indicates that the cancer has spread to
distant areas of the body.
. PHNS Staging System
(Japanese)
P-factor (Peritoneal dissemination)
H-factor (The presence of hepatic
metastases)
N-factor (Lymphnodes involvement)
S-factor (Serosal invasion)
Physical examination
LABORATORY TESTS
blood test
• check for anemia(may be caused by bleeding, liver dysfunction, or
poor nutrition.
• test for the presence of H. pylori bacteria.
Fecal occult blood test (FOBT)
Tumor markers
• CEA:carcino-embryonic antigen
• CA19-9:carbohydrate antigen
• CA724:carbohydrate antigen
The best way to stage the tumor locally is via endoscopic
ultrasound , it gives (80%) information about the depth of
tumor penetration into the gastric wall, and can usually show
enlarged (>5 mm) perigastric and celiac lymph nodes.
ENDOSCOPIC MUCOSAL RESECTION
Gastric cancer
lesion confined
to mucosa
layer
Endoscopic
ultrasound (EUS)
is helpful in
staging GC
ENDOSCOPIC FEATURES OF GASTRIC
CANCER
Esophagogastro
duodenoscopy
(EGD)
endoscopy has
become the
gold standard
for the
diagnosis of
gastric
malignancy.
Biopsy . taking a small piece of tissue from the stomach to look
at under a microscope for signs of cancer cells. It might done
during an endoscopy.
RADIOLOGIC DIAGNOSIS
Distal GC Proximal GC Linitis plastica
X-ray test. with barium. The fluid coats the stomach and
makes it show up more clearly on X-rays.
CT SCAN TEST
MRI : benign regional lymph nodes
Positron Emission Tomography Scanning
Whole-body PET scanning uses the principle that tumor
cells preferentially accumulate positron-emitting 18F-
fluorodeoxyglucose.
This modality is most useful in the evaluation of distant
metastasis in gastric cancer but can also be useful in
locoregional staging.
PET scan is most useful when combined with spiral CT
(PET-CT)95 and should be considered before major surgery
in patients with particularly high-risk tumors or multiple
medical comorbidities
POSITRON EMISSION TOMOGRAPHY
(PET).
PET \ CT SCAN
DETECTION OF EARLY GASTRIC
CANCER
• Endoscopic screening
general population or high risk persons
• Careful observation
• Japan is the only country that had conducted
large nationwide mass population screening of
asymptomatic
individuals for gastric malignancy
DIFFERENTIAL DIAGNOSIS
Gastric Gastric
Ulcer
Cancer
X-ray showing Gastric
ulcer With symmetrical
radiating Mucosal folds. X-ray showing Extensive
By histology, no evidence carcinoma involving
of the cardia & Fundus
Malignancies was
observed.
Pyloric stenosis
IF YOU SEE ULCER ASK UR SELF…BENIGN OR
MALIGNANT?
BENIGN MALIGNANT
Round to oval punched out Irregular outline with
lesion with straight walls & flat necrotic or hemorrhagic
smooth base base
Smooth margins with normal Irregular & raised margins
surrounding mucosa
Mostly on lesser curvature Anywhere
Majority<2cm Any size
Normal adjoining rugal folds Prominent & edematous
that extend to the margins rugal folds that usually do
of the base not extend to the
Treatment
Surgical resection is the only curative treatment for gastric cancer.
Obvious exceptions include patients who cannot tolerate an abdominal
operation, and patients with overwhelming metastatic disease.
The goal of curative surgical treatment is resection of all tumor. Thus, all
margins (proximal, distal, and radial) should be negative and an adequate
lymphadenectomy performed.
Treatment
Generally, the surgeon strives for a grossly negative margin of at least 5 cm.
Some gastric tumors, particularly the diffuse variety, are quite infiltrative and
tumor cells can extend well beyond the tumor mass; thus, gross margins
beyond 5 cm may be desirable.
More than 15 resected lymph nodes are required for adequate staging.
The primary tumor may be resected en bloc with adjacent involved organs
(e.g., distal pancreas, transverse colon, or spleen) during the course of curative
gastrectomy.
Palliative gastrectomy may be indicated in some patients with obviously
incurable disease, but most patients presenting with stage IV gastric cancer
can be managed without major operation.
Extent of Gastrectomy
The standard operation for gastric cancer is radical subtotal gastrectomy.
Subtotal gastric resection typically entails ligation of the left and right gastric
and gastroepiploic arteries at the origin, as well as the en bloc removal of
the distal 75% of the stomach, including the pylorus and 2 cm of
duodenum, the greater and lesser omentum, and all associated lymphatic
tissue.
Reconstruction is usually by Billroth II gastrojejunostomy, but if a small
gastric remnant is left (<20%), a Roux-en-Y reconstruction is considered.
The operative mortality is around 2 to 5%. Radical subtotal gastrectomy is
generally deemed to be an adequate cancer operation in most Western
countries, provided that the contingencies stated result in tumor-free
margins, >15 lymph nodes, and the resection of all gross tumor.
In the absence of involvement by direct extension, the spleen and pancreatic
tail are not removed.
Extent of Lymphadenectomy
The Japanese Research Society for Gastric Cancer has numbered the lymph node
stations that potentially drain the stomach.
Generally these are grouped into level D1 (i.e., stations 3 to 6), level D2 (i.e.,
stations 1, 2, 7, 8, and 11), and level D3 (i.e., stations 9, 10, and 12) nodes.
Generally, D1 nodes are perigastric, D2 nodes are along the hepatic and splenic
arteries, and D3 nodes are the most distant.
The operation described above (radical subtotal gastrectomy in the Extent of
Gastrectomy section), which is by far the most commonly performed procedure in
the United States for gastric cancer, is called a D1 resection because it removes
the tumor and the perigastric D1 nodes.
Extent of Lymphadenectomy
The standard operation for gastric cancer in Asia and specialized U.S. centers is
the D2 gastrectomy, which involves a more extensive lymphadenectomy (removal
of the D1 and D2 nodes).
In addition to the tissue removed in a D1 resection, the standard D2 gastrectomy
removes the peritoneal layer over the anterior mesocolon and selectively over
the pancreas, along with nodes along the hepatic and splenic arteries, and the
crural nodes.
Extent of Lymphadenectomy
Splenectomy and distal pancreatectomy are not routinely performed, because this
clearly has been shown to increase the morbidity of the operation. The purported
survival advantage of D2 gastrectomy in gastric cancer is shown in Table 26-20,
which shows the 5-year survival rates for gastric cancer stratified by pathologic
stage for the United States and Japan. Unfortunately, the randomized prospective
trials that have been performed have not confirmed this survival advantage, but
the morbidity and mortality in the D2 group was higher This was mostly
attributable to the splenectomy and distal pancreatectomy, which are no longer
routinely done as part of the D2 gastrectomy.
Gastric Cancer 5-Year Survival and
Operative Mortality in the USA and Japan
Maruyama (Japan), American College of
1971–1985 Surgeons, 1982–1987
No. patients 3176 18,365
Stage I 91% 50%
Stage II 72% 29%
Stage III 44% 13%
Stage IV 9% 3%
Operative mortality 1% 7%
Randomized Trials Comparing D1 and D2
Gastrectomy for Gastric Cancer
Authors Numbe Type of Postoperative Postoperative 5-Year
r of Surgery Complications Mortality (%) Survival (%)
Patients (%)
Bonenkamp et al. 711 D1 25 4 45
D2 43 10 47
Cuschieri et al. 400 D1 28 6.5 35
D2 46 13 33
Chemotherapy and Radiation for
Gastric Cancer
In general, the actuarial 5-year survival for resected gastric adenocarcinoma
stages 1, 2, and 3 is about 75%, 50%, and 25%, respectively.
Because most surgical patients have stage 2 disease or greater, it is common to
refer gastric cancer patients postoperatively to a medical and/or radiation
oncologist.
Adjuvant treatment with chemotherapy (5-fluorouracil and leucovorin) and
radiation (4500 cGy) has demonstrated a survival benefit in resected patients with
stage II and III adenocarcinoma of the stomach.
Chemotherapy and Radiation for Gastric Cancer
• Adequacy of lymphadenectomy has clearly been shown to impact survival,
particularly in patients with stage III gastric cancer it has been suggested that
the benefits of adjuvant chemoradiation shown in this study would be
vitiated by an adequate operation.
• A recently published study from the Japan Clinical Oncology Group showed
a 69% overall 5-year survival rate in patients with clinically curable T2b, T3,
and T4 gastric cancer, treated with D2 gastrectomy alone (no chemotherapy)
• There was no incremental benefit from para-aortic lymph node dissection.
There is no indication for the routine use of radiation alone in the adjuvant
setting, but in certain patients, it can be effective palliation for bleeding or pain.
In patients with gross unresectable, metastatic, or recurrent disease, palliative
chemotherapy has not been demonstrated to conclusively prolong survival,
but occasionally, a patient has a dramatic response. These patients should be
considered for clinical trials. Agents that have shown activity against gastric
cancer include 5-fluorouracil, cisplatin, doxorubicin, and methotrexate.
Neoadjuvant treatment of gastric adenocarcinoma is being evaluated,
particularly in patients with clinical T3 or N1 disease.
Endoscopic Resection
• It has been demonstrated initially at numerous East Asian centers that
some patients with early gastric cancer can be adequately treated by
an EMR.
• Small tumors (<3 cm) confined to the mucosa have an extremely low
chance of lymph node metastasis (3%), which approaches the operative
mortality rate for gastrectomy.
• If the resected specimen demonstrates no ulceration, no
penetration of the muscularis mucosae, no lymphatic invasion, and
size <3 cm, then the risk of lymph node metastases is less than 1%.
• Thus, some patients with early gastric cancer might be better treated
with the endoscopic technique.
• Currently, this should be limited to patients with tumors <2 cm in size
that are node negative and confined to the mucosa on EUS, in the
absence of other gastric lesions.
REFERENCES
http://www.healthline.com/health/gastric-cancer#Diagnosis5
http://www.webmd.com/cancer/stomach-gastric-cancer?page=2
http://www.mayoclinic.org/diseases-conditions/stomach-
cancer/diagnosis-treatment/diagnosis/dxc-20202339
https://www.nlm.nih.gov/medlineplus/ency/article/000223.
htm
