THE GASTRICCARCINOMA

Prof. Faisal Ghani SiddiquiFCPS; PGDip-bioethics; MCPS-HPE

Preamble

• Epidemiology• Aetiologic factors• Pathology• Clinical features• Investigations• Treatment

Adenocarcinoma -Epidemiology

• Incidence in USA/western Europe• Leading cause of death in Asia/Eastern

Europe• Elderly• Blacks• Low SE status

What causes Gastric Cancer?

Gastric Cancer

• Pernicious anaemia• Blood group A• Family history of gastric cancer

Gastric Cancer Diet

• High fat diet• Pickled, preserved food• Tobacco• Fresh fruit and vegetables• Vitamin C• Regular aspirin

Gastric CancerGenetic Mutations

• Deletion or suppression of p53• Overexpression of COX-2• CDH1

Gastric Cancer Pre-malignant

Conditions• Polyps• Atrophic gastritis• Benign gastric ulcer• Gastric ramnant

Gastric CancerPathology

Malignant Neoplasms of the Stomach

PrimaryAdenocarcinoma (94%)Lymphoma (4%)Malignant GIST (1%)

Haematogenous spreadBreastMalignant melanoma

Direct invasionPancreas; Liver; colon; ovary

Gastric CancerGross Appearance

PolypoidFungatingUlcerativeScirrhous

Gastric CancerHistology –Lauren

Classification

IntestinalDiffuse

Unclassified

Gastric CancerTNM staging

Tis Intaepithelial tumourT1 Tumour invades LP or submucosaT2 Tumour invades muscularis propria or

subserosaT3 Tumour penetrates serosa without

invasion of adjacent structuresT4 Tumour invades adjacent structures

Gastric CancerTNM staging

N0 No regional lymph node metastasesN1 Metastasis in 1 to 6 regional lymph

nodesN2 Metastasis in 7 to 15 regional lymph

nodesN3 Metastasis in more than 15 regional

lymph nodes

Gastric CancerTNM staging

M0 No distant metastasisM1 Distant metastasis

Gastric CancerClinical Manifestations

Symptoms• Weight loss• Decreased food intake• Abdominal pain• Nausea, vomiting and bloating• Acute GI bleeding• Chronic GI bleeding• Dysphagia

Trousseau’s syndrome(thrombophlebitis)

Acanthosis

Nigracans

Clinical Signs

• Cervical, supraclavicular and axillary lymphadenopathy

• Pleural effusion• Aspiration pneumonitis• Abdominal mass• Sister Joseph’s nodule• Ascites• Rectal shelf of Blumer

Rudolph Virchow

Gastric CancerDiagnostic Evaluation

Prompt upper endoscopy if …• New onset of dyspepsia >45 years• Dyspepsia with alarm symptoms

(weight loss, anaemia, recurrent vomiting, bleeding)

• Dyspepsia & family h/o gastric carcinoma

Preoperative Staging

• Abdominal / pelvic CT scanning• Endoscopic ultrasound (EUS)– Depth of the tumour– Enlarged perigastric/coeliac lymph

nodes

Gastric CancerTreatment

Surgical Resection & Adequate

Lymphadenectomyis the only curative treatment

except• Metastases• Co-morbid

Surgical Resection

• Resection of tumour• Grossly negative margin of at least 5 cms • Partial gastrectomy• Confirmed on frozen section• En block resection of adjacent involved

organs

Extent of Gastrectomy

• Radical subtotal gastrectomy (Distal tumour)

• Total gastrectomy(Proximal tumour)

Lymphadenectomy

• D1: stations 3-6• D2: stations 1,2, 7,8 and 11• D3: stations 9, 10 and 12

Survival benefit to adjuvant radio-chemotherapy

is marginal in patients who have undergone adequate resection

In gross unresectable, metastatic tumour

Role of palliative chemotherapy

is uncertain