Gastric cancer

1
Gastric cancer
2
CLASSIFICATION

• Adenocarcinoma (95)
• Lymphoma (4)
• Leiomyosarcoma (GIST-malignant gastrointestinal
  stromal tumors)
• Rare carcinoid, angiosarcoma, squamous cell CA.
• Metastatic lesion of
• Breast,
• Colon,
• Pancreas,
• Melanoma.

3

• CARCINOMA STOMACH

4
Epidemiology

• The second most common fatal malignancy in the
  world (after lung cancer)
• Incidence
• High in Japan, S.America, Korea, Russia
• Age above 50 years
• Sex M gt F ( 21 )
• Site
• Antrum ( 50 )
• Gastric body ( 20- 30 )
• Cardia ( 20 )

5

• Risk Factors for Gastric Adenocarcinoma
• Definite
  Familial adenomatous polyposis (FAP)
• 
  Gastric adenoma
• 
  Dysplasia
• Helicobacter pylori
  infection
• Chronic
  atrophic gastritis
• Intestinal
  metaplasia
• Hereditary
  nonpolyposis
• colorectal cancer
  (HNPCC)
• Postgastrectomy
• 
  First-degree relative with gastric cancer
• Probable Peutz-Jeghers syndrome
• Cigarette
  smoking
• Low
  aspirin intake
• High salt
  intake
• Low intake
  of fresh fruits and vegetables
• Pernicious
  anemia

6

• Clinical Manifestation
• Early Gastric Cancer
• Asymptomatic 80
• Advanced Gastric Cancer
• Weight loss ( 62 ) due to anorexia and early
  satiety is the most common symptoms
• Abdominal pain ( 52) common
• Nausea / vomiting
• Chronic occult blood loss is common
• GIT bleeding (5)
• Dysphagia (cardia involvement)
• Pyloric outlet obstruction ( antrum involment)

7
(No Transcript)
8
Contd

• 7. Paraneoplastic syndromes
• Thrombophlebitis (trousseaus sign)
• Neuropathies
• Nephrotic syndrome
• DIC
• Acanthosis nigricans
• Seborrheic dermatosis

9
Signs

• Cachexia, pallor
• Signs of bowel obstuction
• Hepatomegaly
• Ascites
• Edema of lower extremity

10
Sites of Metastatic Spread

• Umblicus ( sister josephs nodule)
• Ovaries ( krukenberg tumor)
• Lt. Supraclavicular lymh node ( virchows node)
• Pouch of douglass (rectal shelf of Blumar)

11
Contd

• Target organs
• Liver
• Lung
• Peritoneam
• Bone marrow
• Kidney
• Bladder
• Bone
• Brain
• Thyroid

12
INVESTIGATIONS

• Labs
• CBC
• LFTS
• Gastric carcinoma-associated Ag
• MG7-Ag

13
Imaging Studies

• EGD safe, simple, providing a permanent color
  photographic record.
• Obtains tissue for diagnosis.
• UGIS detects large tumors, but only occasionally
  detects extension into esophagus or duodenum,
  especially if small or submucosal.

14
(No Transcript)
15
Imaging Studies

• CXR done to evaluate for metastases.
• USG
• CT scan or MRI of chest, abdomen, pelvis
  evaluate local disease process, and areas of
  spread.
• PET Scan Whole body
• Tumor cell preferentially accumulate
  positron-emitting 18F fluorodeoxyglucose.

16
Contd

• Endoscopic ultrasound becoming extremely useful
  as a staging tool, when CT fails to show T3, T4,
  or metastatic disease.
• Cannot reliably distinguish between tumor and
  fibrosis.
• Overall staging accuracy of 75
• Poor for T2 lesions (38)
• Better for T1(80), T3 (90)

17
Gastric cancer confined to mucosa
18
Classification
19
Macroscopically

• Borrmans classification
• Type 1 Protruded
• Type 2
• 2a Elevated
• 2b Flat
• 2c Depressed
• Type 3 Excavated

20
Macroscopic Subtypes

• Superficial spreading
• Polypoid (well differentiated)
• Fungating
• Ulceration
• linitis plastica
• Leather bottle stomach
• Poor prognosis
• Usually undifferentiated

21
microscopically

• WHO Classification
• Adenocarcinoma
• Papillary adenocarcinoma
• Tubular adenocarcinoma
• Mucinous adenocarcinoma
• Signet-ring cell carcinoma
• Adenosquamous carcinoma
• Squamous cell CA
• Small cell CA
• Undifferentiated CA
• Others

• Lauren Classification
• Intestinal type (53)
• Diffuse type (33)
• Unclassified (14)
• Ming Classification
• Expanding type (67)
• Infiltrative type (33)

22
Contd

• Intestinal
• Environmental
• Gastric atrophy
• Men gt women
• Increasing vid age
• Gland formation
• Hematogenous spread
• Good Prognosis

23
Contd

• Diffuse
• Blood type A
• Women gt men
• Younger age
• Poorly differentiated
• Transmural\lymphatic
• Poor prognosis

24

• STAGING

25
PRIMARY TUMOR (T) PRIMARY TUMOR (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ intraepithelial tumor without invasion of the lamina propria
T1 Tumor invades lamina propria or submucosa
T2 Tumor invades muscularis propria or subserosa
T2a Tumor invades muscularis propria
T2b Tumor invades subserosa
T3 Tumor penetrates serosa (visceral peritoneum) without invasion of adjacent structures
T4 Tumor invades adjacent structures
REGIONAL LYMPH NODES (N) REGIONAL LYMPH NODES (N)
NX Regional lymph node(s) cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in 1 to 6 regional lymph nodes
N2 Metastasis in 7 to 15 regional lymph nodes
N3 Metastasis in more than 15 regional lymph nodes
DISTANT METASTASIS (M) DISTANT METASTASIS (M)
MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
26
STAGE GROUPING STAGE GROUPING STAGE GROUPING STAGE GROUPING
Stage 0 Tis N0 M0
Stage 1A T1 N0 M0
Stage IB T1 N1 M0
Stage IB T2a/b N0 M0
Stage II T1 N2 M0
Stage II T2a/b N1 M0
Stage II T3 N0 M0
Stage IIIA T2a/b N2 M0
Stage IIIA T3 N1 M0
Stage IIIA T4 N0 M0
Stage IIIB T3 N2 M0
Stage IV T4 N13 M0
Stage IV T13 N3 M0
Stage IV Any T Any N M1
From AJCC Cancer Staging Manual, 6th ed. New York, Springer-Verlag, 2001. From AJCC Cancer Staging Manual, 6th ed. New York, Springer-Verlag, 2001. From AJCC Cancer Staging Manual, 6th ed. New York, Springer-Verlag, 2001. From AJCC Cancer Staging Manual, 6th ed. New York, Springer-Verlag, 2001.
27
Staging
28
Prognostic Features

• Depth of invasion through gastric wall, presence
  or absence of regional lymph node involvement
• The greater number of positive nodes, the greater
  the likelihood of local or systemic failure
  postoperatively

29

• Mode of spread
• Direct
• Lymphatic
• Hematologic
• Transcoelomic route

30
Management

• SURGERY
• EMR ..EMD
• PDT
• CHEMOTHERAPY
• RADIATION THERAPY

31
Surgery

• The only curative tx for gastric cancer
• Except
• Cant tolerate abdominal surgery
• Overwhelming metastasis
• Palliation is poor with non-resective operations
• GOAL resect all tumors, with negative margins
  (5cm) and adequate lymphadenectomy
• Enbloc resection of adjacent organ is done if
  needed

32
Proximal / Cardia

• Proximal Gastrectomy Increased morbidity /
  mortality
• Buhl, et al.
• Dumping, heartburn, reduced appetite
• Norwegian Stomach Ca Trial
• Prox. gastrectomy morbid / mortal 52 16
• Total gastrectomy morbid / mortal 38 8
• Total gastrectomy considered procedure of choice
  for proximal gastric lesions

33
Distal Tumors

• Account for 50 of all gastric cancers
• No 5-year survival difference b/w subtotal vs.
  total Gastrectomy
• Subtotal appropriate if negative margins
• Recurrence vs. nonrecurrence depends on margin of
  3.5 cm vs. 6.5 cm

34
(No Transcript)
35
Residual Disease R Status

• Tumor status following resection.
• Assigned based on pathology of margins.
• R0- no residual gross or microscopic disease.
• R1- microscopic disease only.
• R2- gross residual disease.
• Long term survival only in R0 resection.

36
D Nomenclature

• Describes extent of resection and
  lymphadenectomy.
• D1- removes all nodes within 3cm of tumor.
• D2- D1 plus hepatic, splenic, celiac, and left
  gastric nodes.
• D3- D2 plus omentectomy, splenectomy, distal
  pancreatectomy, clearance of porta hepatis nodes.
• Current standards include a D1 dissection only.

37

• Radical subtotal gastrectomy
• D1 resection (standard in USA)
• Removes tumor and N1
• D2 resection(standard in Asia)
• Gastrectomy and N1 and N2 removal
• Removes the peritoneal layer over the pancreas
  and anterior mesocolon
• Removes LN along hepatic splenic
• Splenectomy and distal pancreatectromy not
  routinely removed due to higher morbidity postop.

38
Radical subtotal Gastrectomy

• D1 resection (standard in USA)
• Removes tumor and N1
• D2 resection(standard in Asia)
• Gastrectomy and N1 and N2 removal
• Removes the peritoneal layer over the pancreas
  and anterior mesocolon
• Removes LN along hepatic splenic
• Splenectomy and distal pancreatectromy not
  routinely removed due to higher morbidity postop.

39
Outcome

• 5-year survival for a curative resection is
  30-50 for stage II disease, 10-25 for stage III
  disease.
• Adjuvant therapy because of high incidence of
  local and systemic failure.
• A recent Intergroup 0116 randomized study offers
  evidence of a survival benefit associated with
  postoperative chemoradiotherapy

40
Outcomes
41
Complications

• Mortality 1-2
• Anastamotic leak, bleeding, ileus, transit
  failure, cholecystitis, pancreatitis, pulmonary
  infections, and thromboembolism.
• Late complications include dumping syndrome,
  vitamin B-12 deficiency, reflux esophagitis,
  osteoporosis.

42
Palliation

• 20 30 of gastric cancer presents with stage IV
  disease
• Relief of symptoms with minimal morbidity
• Surgical palliation eg. GOO
• Percutaneous, endoscopic, radiotherapuetic
  techniques

43

• Nonoperative tx
• Laser recanalization
• Endoscopic dilatation
• Metalic stenting

44
Endoscopic Resection of Gastric Carcinoma

• Criteria
• Tumor lt 2cm in size
• No lymph node involved
• Tumor confined on the mucosa
• No mucosal ulceration
• No lymphatic invasions
• Intestinal type
• No evidence of multiple gastric cancers

45
Photodynamic therapy

• Reject surgical intervention
• Comorbid condtions render risk of surgical
  intervention
• Complete remission
• Early intestinal type (80)
• Limited diffuse type (50)

46
Adjuvant Treatment for Gastric Carcinoma

• Chemotherapy
• 5-fluorouracil, mitomycin, cisplatin, doxorubicin
  and methotrexate
• Can not prolong survival in unresectable,
  metastatic or recurrent diseases
• Radiation
• Effective in palliation for pain and bleeding
• Studies show improved survival, lower rates of
  local recurrence when compared to surgery alone.

47
Recurrence

• After Gastrectomy quite high
• 40 80
• Most occur within first 3 years
• Locoregional failure 38 45
• Anastomosis, gastric bed and regional nodes
• Peritoneal dissemination 54

48
Surveillance

• Recurrence high first 3 years
• Complete HP Examination every 4 moths for 1
  year
• Then every 6 moths for 2 years
• Annually after
• CBC, LFT , as clinically indicated
• CXR, CT abdomen/pelvis- ? Routinely
• Annual Endoscopy for subtotal Gastrectomy

49
Screening of Gastric Cancer

• Patients at risk for Gastric CA should undergo
  yearly endoscopy and biopsy
• Familial adenomatous polyposis
• Hereditary nonpolyposis colorectal cancer
• Gastric adenomas
• Intestinal metaplasia or dysplasia
• Remote gastrectomy or gastrojejunostomy

50
Prevention

• Eradication of H. Pylori
• Supplementation with Antioxidants
• Aspirin and NSAID
• Green tea

51

• Gastric Lymphomas

52
Epidemiology

• Stomach most common site for lymphomas in GI
  system
• Primary gastric lymphoma uncommon
• 5 of gastric cancer, 2 of lymphomas
• Vague symptoms
• Epigastric pain, early satiety and fatigue
• Bleeding uncommon
• 50 have anemia on presentation
• 6th and 7th decade (MF is 21)
• Most commonly in antrum

53
Pathology

• Multiple classification systems
• Most common diffuse large B cell 55
• Marginal B cell lymphoma of MALT type 40
• Uncommon types

54
Pathology

• Diffuse large B-cell
• Usually primary
• May occur from progression of less aggressive
  lymphomas (chronic lymphocytic leukemia / small
  lymphocytic lymphoma, follicular lymphoma or
  MALT)
• Risk factors
• Immunodeficiency's, H. pylori

55
Gastric MALT extranodal marginal zone lymphomas
of MALT type

• Commonly preceded by H. pylori associated
  gastritis
• Predicts responsiveness to tx by H. pylori
  eradication

56
Treatment

• Multimodality early stage
• Resection controversial
• Chemo/rads alone
• Perforation w/ chemo 5
• CHOP cyclophosphamide, hydroxy- doxorubicin,
  oncovin, predinose)
• Anti CD20 monoclonal Ab, rituximab
• 5 year survival
• Sx/Chemo/Rad 82
• Chemo/Rad 84.4

57
Treatment

• Radiation
• Limited in large tumors
• Local control 100 lt 3 cm
• 60 70 if gt 6 cm
• Risk of complications 30 at 10 years

58
Treatment

• Late-stage
• Not amenable to surgery chemo
• MALT/very limited diffuse large B-cell
• H. pylori eradication alone
• 75
• Repeat endoscopy in 2 moths biannual endoscopy
  for 3 years
• Failure of above increased if
• Transmural, node

59

• Gastric Sarcoma

60
Epidemiology

• Arise from mesenchymal components of gastric wall
• 3 of all gastric CA
• GIST most common
• Stomach (60-70)
• After 4th decade
• Mean age 60

61
GIST - Pathology

• Initially thought to arise from smooth muscle
  cells previously classified as leiomyoma /
  leiomyosarcoma
• Histotology
• Muscularis propria likely from cells of Cajal
• GIST
• Cellular
• Spindle cell
• Pleomorphic mesenchymal tumors

62

• No current system for staging
• Prognosis
• Mitotic frequency
• Low benign
• High malignant
• Other signs of malignancy
• Size gt 5 cm
• Cellular atypia,
• Necrosis or local invasion.

63
Clinical

• Most common presentation
• GI bleeding, pain abdomen, dyspepsia
• Endoscopy first diagnostic test
• With biopsy 50
• CT Abdomen best , since neoplasm grows
  intramurally
• Double-contrast UGI smooth edged filling defect

64
Treatment

• Surgery
• Negative margin (en-bloc if adjacent organs)
• Avoid rupture of tumor to prevent peritoneal
  seeding
• LN mets rare (lt10) no added benefit
• Most recurrences in first 2 years
• Local disease with associated. liver mets
• 5 year survival 48 (19 56)
• Adjuvant tx
• Radiation no proven benefit
• 5 respond to doxorubicin
• Imatinib (Gleevec) 54 partial response
• unrespectable GIST, mets

65
GASRTIC CARCINOID TUMORS

• O.3 Gastric neoplasm
• Mean Age 62
• Sex M F 11
• Risk factors
• Pernicious anemia
• Chronic atrophic gastritis
• Hypergastrinemia
• Zollinger Ellison syndrome

66
CLINICAL

• Asymptomatic ,dyspepsia
• EGD Irregularly shaped erythematous dimple in
  the centre of submucosal mass
• EUS
• Depth of invasion
• Submucosal biopsy
• CT And MRI Hepatic involvement

67
MANAGMENT

• Controversial
• Secondary Carcinoid
• EMR small tumor
• Surgical resection large tumor esp. involvement
  of Muscularis propria
• Sporadic Carcinoid
• Surgical resection with lymph node sampling
• Survival Five years
• Nonmetastatic disease gt 95
• Metastases gt 50

68

• 
  THANX