Stomach Neoplasms

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Stomach Neoplasms

• Professor Ravi Kant
• FRCS (England), FRCS (Ireland), FRCS(Edinburgh),
  FRCS(Glasgow), MS, DNB, FAMS, FACS, FICS,
• Professor of Surgery

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Stomach Neoplasm

• Maltoma
• Lymphoma
• GIST
• CA stomach

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GASTRIC LYMPHOMA
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• Gastric Lymphoma
• Most common primary GI Lymphoma .
• Its increasing in frequency.
• Presentation
• Similar to gastric carcinoma.
• May reveal peripheral adenopathy, abdominal
  mass or splenomegaly.

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• Diagnosis
• 1.EGD 2.contrast GI x-ray.
• 3.CT guided fine needle biopsy.
• Treatment
• Gastric Lymphoma Rx is Surgery
• (Other organs- preferred Rx of Lymphoma is
  Chemotherapy or Radiotherapy)

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Maltoma

• Mucosa associated lymphoid tumour

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MALTOMA

• Aetiology H Pylori
• Rx Rx of H Pylori
• Triple drugs

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GIST
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What are GIST??

• Gastrointestinal Stromal Tumors are uncommon
  mesenchymal tumors that arise in the wall of the
  gastrointestinal tract
• It is believed to originate from an intestinal
  pacemaker cell called the interstitial cell of
  Cajal.

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Cajal cell

• An intestinal pacemaker cell, has been proposed
  the cellular origin of GISTs. It has
  characteristics of both smooth muscle and neural
  differentiation on ultrastructural examination

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KIT

• role of the KIT and platelet-derived growth
  factor receptor (PDGFR) tyrosine kinase receptors
  
• KIT receptor tyrosine kinase (KIT RTK)

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KIT

• approximately 5 of GIST cells show not
  activation and aberrant signaling of the KIT
  receptor, but rather mutational activation of a
  structurally related kinase, PDGFR- (PDGFRA).
• 90 rate of mutations seen in a more recent
  series searching for potential mutations in each
  of exons 11, 9, 13, and 17

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CD117 CD34 Actin Desmin S-100
GIST - -
Desmoid tumor - - -
True leiomyosarcoma - - -
Schwanoma - - -

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Diagnosis

• CT is the common mode of diagnosis
• FDG PET is mandatory
• ?PET CT scan is ideal
• MR

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GIST chemoresistance

• ? P-glycoprotein the product of the multidrug
  resistance-1 (MDR-1) gene
• ? MDR protein

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Distribution

• Stomach 50-60
• Small bowel 20-30
• Large bowel 10
• Esophagus 5
• Else where in abdomen 5

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Symptoms

• Abdominal pain
• Dysphagia
• Gastrointestinal bleeding
• Symptoms of bowel obstruction
• Small tumors may be asymptomatic

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Cytologically

• Spindle cell GISTs
• Epithelioid cell GISTs
• Although GISTs can differentiate along either or
  both cell types, some show NO significant
  differentiation at all

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Diagnosis

• MUST BE DONE IMMUNOCHEMICALLY
• The CD34 antigen (70-78)
• The CD117 antigen (72-94)

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Malignant Versus Benign
Size Mitotic count
Very Low risk lt2 cm lt5/50 HPF
Low risk 2-5 cm lt5/50 HPF
Intermediate risk lt5 cm 5-10 cm 6-10/50 HPF lt5/50 HPF
High risk gt5 cm gt10 cm Any size gt5/50 HPF Any count gt10/50 HPF
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predictors of survival

• Male sex,
• Tumor size gt 5cm
• Incomplete resection

significant on multivariate analysis
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Treatment

• Surgical excision is primary treatment option but
  recurrence rates are high
• Resistant to standard chemotherapy regimens due
  to over-expression of efflux pumps
• Radiation therapy limited by large tumor sizes
  and sensitivity of adjacent bowel

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IMATINIB

• Since activation of Kit played a crucial role in
  the pathogenesis of GIST, inhibition of Kit would
  be therapeutic ?

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IMATINIB

• Orally bioactive tyrosine kinase inhibitor
• Shown to be effective against GIST tumors in two
  trials in the US and Europe reported in 2001
  2002

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• Gastrointestinal Stromal Tumor GIST
• Previously leiomyoma leiomyosarcoma.
• lt1
• Rarely cause bleeding or obstruction.
• The origin Intestinal Cells of Cajal ICCs
  autonomic nervous system.
• The distinction b\w benign malignant is
  unclear. In general terms, the larger the tumor
  greater mitotic activity, the more likely to
  metastases.
• The stomach is the most common site of GIST.

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• Usually are discovered incidentally on endoscopy
  or barium meal
• The endoscopic biopsies may be uninformative as
  the overlying mucosa is usually normal
• Small tumors?wedge resection
• Larger ones?gastrectomy

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GIST

• Case history-submucosal
• Cajal Cell
• Gene KIT
• PGDRF
• Diagnosis
• CT
• PET

• Rx
• Surgery
• Chemoresistance
• Imatininb
• Sumanitib
• Prognosis
• Predictor factors

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GASTRIC CARCINOMA
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GASTRIC NEOPLASM
Benign
Malignant

• Epithelial
• Mesenchymal

1.Primary Adenocarcinoma Gastrointestinal stromal
tumors GIST Lymphoma
2. Secondary invasion from adjacent tumors.
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GASTRIC CA
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Gastric Carcinoma
Epidemiology Risk Factors
DEFINITION
Malignant lesion of the stomach.

• 55 year old Japanese male who is living in Japan
  working in industry.

Incidence of Gastric Carcinoma Japan 70
in100,000/year Europe 40 in 100,000/year UK 15 in
100,000/year USA 10 in 100,000/year It is
decreasing worldwide.
Can occur at any age But Peak incidence Is 50-70
years old. It is more aggressive In younger ages.
Twice more common In male than in female
Studies have confirmed that incidence decline
in Japanese immigrant to America.
Japan has the world highest Rate of gastric
cancer.
dust ingestion from a variety of industrial
processes may be a risk.
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Gastric Carcinoma

• Risk Factors

Environmental 1.H.pylori infection
Sero()patients have 6-9 folds risk 2.low
socioeconomic Status 3. nationality
(JAPAN) 4. Diet (prevention)
Predisposing 1. Pernicious anaemia
atrophic gastritis (achlorhydra) 2.
Previous gastric resection 3. Chronic peptic
ulcer (give rise to 1) 4. Smoking. 5.
Alcohol.
Genetic 1.Blood group A 2.HNPCC Hereditary
non-polyposis colon cancer.
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Clinical Presentation

• Most patients present with advanced stage..
• why?
• They are often asymptomatic in early stages.

Common clinical Presentation
The patient complained of loss of appetite that
was followed by weight loss of 10Kg in 4 weeks.
He had notice epigastric discomfort
postprandial fullness. He presented to the ER
complaining of vomiting of large quantities of
undigested food epigastric distension.
epigastric pain Bloating early satiety nausea
vomiting dysphagia anorexia weight loss
upper GI bleeding (hematemesis, melena, iron
deficiency anemia)
Dyspepsia
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signs

• -Anemia.
• -Wt. loss ( cachexia)
• -Epigastric mass, Hepatomegaly, Ascitis
• -Jaundice.
• -Blumers shelf
• -Virchow's node
• -Sister Mary Joseph node
• -Krukenberg tumor
• -Irish node

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Pathology DIO Classification

• Lauren Classification
• 1. Intestinal Gastric ca.
• It arises in areas of intestinal metaplasia
  to form polypoid tumors or ulcers.
• 2. Diffuse Gastric ca.
• It infiltrates deeply in the stomach without
  forming obvious mass lesions but spreads widely
  in the gastric wall Linitis Plastica
• it has much more worse prognosis
• 3. Mixed Morphology.

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Morphology

• Polypoid
• Ulcerative
• Superficial spreading
• Linitis plastica

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• Gastric cancer can be divided into
• Early
• Limited to mucosa submucosa with or without
  LN (T1, any N)
• gtgt curable with 5 years survival rate in 90.
• Advanced
• It involves the Muscularis.
• It has 4 types( Bormanns classification).
  Type III IV are incurable.

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Staging of gastric cancer
Spread of Gastric Cancer
Direct Spread
Lymphatic spread
T1 lamina propria submucosa
T2 muscularis subserosa
T3 serosa
T4 Adjacent organs
N0 no lymph node
N1 Epigastric node
N2 main arterial trunk
M0 No distal metastasis
M1 distal metastasis
Tumor penetrates the muscularis, serosa
Adjacent organs (Pancreas,colon liver)
What is important here is Virchows node
(Trosiers sign)
Blood-borne metastasis
Transperitoneal spread
This is common Anywhere in peritoneal
cavity (Ascitis) Krukenberg tumor
(ovaries) Sister Joseph nodule (umbilicus)
Usually with extensive Disease where liver
1st Involved then lung Bone
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Complications

• Peritoneal and pleural effusion
• Obstruction of gastric outlet or small bowel
• Bleeding
• Intrahepatic jaundice by hepatomegaly

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Differential Diagnosis

• 1.Gastric ulcer
• 2.Other gastric neoplasms
• 3.Gastritis
• 4.Gastric Polyp
• 5.Crohns disease.

From history, Cancer is not relieved by
antacids Not periodic Not relieved by eating or
vomiting.
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INVESTIGATIONS

• Full blood count IDA-
• LFT,RFT
• Amylase lipase.
• Serum tumor markers (CA 72-4,CEA,CA19-9) not
  specific
• Stool examination for occult blood
• CXR ,Bone scan.

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• Specific
• UGI endoscopy with biopsy
• Double contrast study
• CT, MRI US
• Laparoscopry

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• EGD esophagogastroduodenoscopy
• Diagnostic accuracy is 98
• if up to 7 biopsies is taken.
• Double Contrast barium upper GI x-ray
• Diagnostic accuracy 90
• WHY?

Diagnostic study of Choice
1.Early superficial gastric mucosal lesion can
be missed. 2. cant differentiate b/w benign
ulcer Ulcerating adenocarcinoma.
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X-ray showing Extensive carcinoma involving
the cardia Fundus
X-ray showing Gastric ulcer With symmetrical
radiating Mucosal folds. By histology, no
evidence of Malignancies was observed.
Pyloric stenosis
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• CT,MRI US
• Laparoscopy

Help in assessment of wall thickness, metastases
(peritoneum ,liver LN)
Detection of peritoneal metastases
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UGI ENDOSCOPY

• THE GOLD STANDARD
• It allows taking biopsies
• Safe (in experienced hands)

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UGI ENDOSCOPY,contd.

• You may see an ulcer (25), polypoid mass (25),
  superficial spreading (10),or infiltrative
  (Linitis plastica)-difficult to be detected-
• Accuracy 50-95 it depends on gross appearance,
  size, location no. of biopsies

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IF YOU SEE ULCER ASK UR SELFBENIGN OR MALIGNANT?
MALIGNANT BENIGN
Irregular outline with necrotic or hemorrhagic base Round to oval punched out lesion with straight walls flat smooth base
Irregular raised margins Smooth margins with normal surrounding mucosa
Anywhere Mostly on lesser curvature
Any size Majoritylt2cm
Prominent edematous rugal folds that usually do not extend to the margins Normal adjoining rugal folds that extend to the margins of the base
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Management

• Surgery
• Chemotherapy
• NO PROVEN
  BENEFIT
• Radiotherapy

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Treatment

• Initial treatment
• 1.Improve nutrition if needed by parenteral or
  enteral feeding.
• 2.Correct fluid electrolyte
• anemia if they are present.

• Preoperative Care
• Preoperative Staging is important because we
  dont want to subject the patient to radical
  surgery that cant help him.

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PRE-OPERATIVE CARE

• Careful preoperative staging
• Screen for any nutritional deficiencies
  consider nutritional support
• Symptomatic control
• Blood transfusion in symptomatic anemia
• Hydration
• Prophylactic antibiotics
• ABO cross match
• Ask about current medications allergies
• Cessation of smoking

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BASIC SURGICAL PRINCIPLES

• 3 TYPES TOTAL,SUBTOTAL,PALLIATIVE
• ANTRAL DISEASE?SUBTOTAL GASTRECTOMY
• MIDBODY PROXIMAL? TOTAL GASTRECTOMY

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TOTAL (RADICAL) GASTRECTOMY

• Remove the stomach distal part of esophagus
  proximal part of duodenum greater lesser
  omentum LN
• Oesophagojejunostomy with roux-en-y .

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SUBTOTAL GASTRECTOMY

• Similar to total one except that the PROXIMAL
  PART of the stomach is preserved
• Followed by reconstruction creating anastomosis
  
• ( by gastrojejunostomy, Billroth II )

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PALLIATIVE SURGERY

• For pts with advanced (inoperable) disease
  suffering significant symptoms e.g. obstruction,
  bleeding.
• Palliative gastrectomy not necessarily to be
  radical, remove resectable masses reconstruct
  (anastomosis/intubation/stenting/
• recanalisation)

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POSTOPERATIVE ORDERS

• Admit to PACU
• Detailed nutritional advise (small frequent
  meals)

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Post-Operative Complications

• 1.Leakage from duodenal stump.
• 2.Secondary hemorrhage.
• 3.Nutritional deficiency in long term.

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• 2.Chemotherapy
• Responds well, but there is no effect on
  survival.
• Marsden Regimen
• Epirubicin, cisplatin 5-flurouracil (3 wks)
• 6 cycles
• Response rate 40 .
• 3. Radiotherapy
• Postperative-radiotherpy may decrease the
• recurrence.

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Preventive measures

• By diet
• Convincing
• vegetable fruits.
• Probable
• Vit. C E
• Possible
• Carotenoids, whole grain cereals and green tea.
• Smoking cessation
• Cessation of alcohol intake

Early diagnosis remains the Key Problem
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PROGNOSTIC FEATURES

• 2 important factors influencing survival in
  resectable gastric cancer
• depth of cancer invasion
• presence or absence of regional LN involvement
• 5yrs survival rate
• 10 in USA
• 50 in Japan

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Bailey Loves short practice of
surgery Clinical surgery ( A. Cuschieri).
E-medicine web site The Washington Manual of
Surgery
THANK U