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GASTRIC TUMOURS

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Title: GASTRIC TUMOURS


1
GASTRIC TUMOURS
  • ? Anatomy of the stomach
  • ? Aetiology of Gastric cancer
  • ? Types of Gastric cancer
  • ? Pathology of Gastric Cancer
  • ? Evaluation of Gastric Cancer
  • ? Treatment of Gastric Cancer

2
ANATOMY
  • ? The stomach J-shaped. The stomach has two
    surfaces (the anterior posterior), two
    curvatures (the greater lesser), two orifices
    (the cardia pylorus). It has fundus, body and
    pyloric antrum.

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BLOOD SUPPLY
  • a. The left gastric artery
  • b. Right gastric artery
  • c. Right gastro-epiploic artery
  • d. Left gastro-epiploic artery
  • e. Short gastric arteries
  • The corresponding veins drain into portal
    system. The lymphatic drainage of the stomach
    corresponding its blood supply.

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Anatomy
  • Stomach has five layers
  • Mucosa
  • Epithelium, lamina propria, and muscularis
    mucosae
  • Submucosa
  • Smooth muscle layer
  • Subserosa
  • Serosa

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AETIOLOGY
  • ? Gastric cancer is the second most common fatal
    cancer in the world with high frequency in Japan.
  • ? The disease presents most commonly in the 5th
    and 6th decades of life and affect males twice as
    often as females.

Contn
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  • ? The cause of the disease multistep process
    but several predisposing factors attributed to
    cause the disease
  • a. Environment e. Atrophic gastritis
  • b. Diet f. Chronic gastric ulcer
  • c. Heredity g. Adenomatous polyps
  • d. Achlorhydria h. Blood group A
  • i. H. Pyloric colonisation

13
TYPES OF GASTRIC CANCER
  • A. Benign Tumours
  • B. Malignant Tumours

14
TYPES OF GASTRIC CANCER
  • A. Benign Tumours
  • B. Malignant Tumours

15
THE BENIGN TUMORS
  • ? Although benign tumors can occur in the stomach
    most gastric tumours are malignant.

16
  • ? The benign groups includes-
  • 1. Non-neoplastic gastric polyps
  • 2. Adenomas
  • 3. Neoplastic gastric polyps
  • 4. Smooth muscles tumours benign
  • (Leiomyomas)
  • 5. Polyposis Syndrome (eg- Polyposis coli,
  • Juvenile polyps and P.J. Syndrome)
  • 6. Other benign tumours are fibromas,
    neurofibromas, aberrat pancreas and
  • angiomas.

17
PATHOLOGY OF GASTRIC (MALIGNANT)
TUMOURS
  • ? The gastric cancer may arise in the antrum
    (50), the gastric body (30), the fundus or
    oesophago-gastric juntion (20).

18
? Types of Malignant Tumours
  • a. Adenocarcinoma
  • b. Leiomyosarcoma
  • c. Lymphomas
  • d. Carcinoid Tumours

19
? The macroscopic forms of gastric cancers are
classified by (Bormann classification) into-
  • 1. Polypoid or Proliferative
  • 2. Ulcerating
  • 3. Ulcerating/Infiltrating
  • 4. Diffuse Infiltrating (Linnitus-
  • Plastica)

20
Microscopically the tumours commonly
adenocarcinoma with range of differentiation.
The most useful to clinician and epidemiologist
is Lauren Histological Classification
  • a. Intestinal gastric cancer
  • b. Diffuse gastric cancer

21
Gastric Carcinoma
  • Diffuse
  • MF 11
  • Onset Middle Age
  • 5 yr surv overall lt10
  • Aetiology
  • Diet
  • H. pylori
  • Intestinal
  • MF 21
  • Onset Middle Age
  • 5 yr surv overall 20
  • Aetiology
  • Unknown
  • Blood group A association
  • H. pylori

22
  • ? Early Gastric Cancer Defined as
    cancer which is confined to the mucosa and
    submucosa regard- less of lymph nodes status.
  • ? Advanced Gastric Cancer Defined as
    tumor that has involved the muscularis propria
    of the stomach wall.

23
Gastric Neoplasm
  • Pathology
  • Gastric dysplasia ---gt precursor of gastric CA
  • Early gastric cancer
  • Limited to the mucosa and submucosa, regardless
    of LN status
  • 70 are well differentiated
  • Cure rate is 90

24
STAGING OF GASTRIC CANCER
  • a. TNM System
  • b. CT Staging
  • c. PHNS Staging System (Japanese)
  • ? P-factor (Peritoneal dissemination)
  • ? H-factor (The presence of hepatic metastases)
  • ? N-factor (Lymphnodes involvement)
  • ? S-factor (Serosal invasion)

25
TNM Classification System
  • Distant metastasis (M)
  • MX Presence of distant metastasis cannot be
  • assessed
  • M0 No distant metastasis
  • M1 Distant metastasis (may be further specified
  • according to size of occurrence)

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SPREAD OF GASTRIC CANCER
  • ? The diffuse type spreads rapidly through
    the submucosal and serosal lymphatic and
    penetrates the gastric wall at early stage, the
    intestinal variety remains localized for a while
    and has less tendency to disseminate.
  • The spread by
  • 1. Direct (loco regional)
  • 2. Lymphatic
  • 3. Blood (Haematogenous)
  • 4. Transcoelomic

28
  • Clinical Manifestation
  • Weight loss due to anorexia and early satiety is
    the most common symptoms
  • Abdominal pain (not severe) common
  • Nausea / vomiting
  • Chronic occult blood loss is common
  • GIT bleeding (5)
  • Dysphagia (cardia involvement)

29
  • Clinical Manifestation
  • Paraneoplastic syndromes ( Trousseaus syndrome
    thrombophlebitis acanthosis nigricans
    hyperpigmentation of axilla and groin peripheral
    neuropathy)
  • Signs of distant metastasis
  • Hepatomegally / ascites
  • Krukenbergs tumor
  • Blummers shelf (drop metastasis)
  • Virchows node
  • Sister Joseph node (pathognomonic of advances
    dse)

30
? SUMMARY
  • ? Often asymptomatic until late stage.
  • ? Marked weight loss
  • ? Anorexia
  • ? Feeling of abdominal fullness or discomfort
  • ? Epigastric mass
  • ? Iron Deficiency Anaemia
  • ? Left supraclavicular mass (Troisiers Sign)
  • ? Obstructive Jaundice (Secondary in porta
  • hepatitis)
  • ? Pelvic mass (Krukenberg)

31
EVALUATION OF GASTRIC CANCER
  • ? History
  • ? Clinical Examination
  • ? Investigations
  • ? The clinical features of gastric cancer may
    arise from local disease, its complications or
    its metastases.

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INVESTIGATIONS
  • A. Upper gastero intestinal endoscopy
  • with multiple biopsy and brush
  • cytology
  • B. Radiology
  • ? CT Scan of the chest and abdomen
  • ? USS upper abdomen
  • ? Barium meal
  • C. Diagnostic laparoscopy

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  • Diagnosis
  • UGIS (double contrast)
  • Endoscopy (Biopsy / Ultrasound)
  • GOLD STANDARD
  • Best pre-operative staging
  • Needle aspiration of LN w/ ultrasound guidance
  • Can even give preop neoadjuvant tx
  • CT scan (intravenous and oral contrast)
  • For pre-operative staging
  • Whole body Positron Emission Tomography scanning
    (PET)
  • Tumor cell preferentially accumulate
    positron-emitting 18F fluorodeoxyglucose.

34
Laboratory
  • Assists in determining optimal therapy.
  • CBC identifies anemia, with may be caused by
    bleeding, liver dysfunction, or poor nutrition.
  • 30 have anemia.
  • Electrolyte panels and LFTs are also essential to
    better characterize patients clinical state.

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Investigations for patients with gastric cancer
  • Endoscopy biopsy
  • Performance status
  • Physiological assessment
  • Cardio-pulmonary function
  • CT chest abdomen
  • EUS (endoscopic ultrasound)
  • Laparoscopy

36
CT scanning
  • Technique
  • Spiral CT of chest and abdomen

37
Laparoscopy
  • Inspect peritoneal surfaces, liver surface.
  • Identification of advanced disease avoids
    non-therapeutic laparotomy in 25.
  • Patients with small volume metastases in
    peritoneum or liver have a life expectancy of 3-9
    months, thus rarely benefit from palliative
    resection.

38
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
  • Menetriers disease
  • Intestinal metaplasia or dysplasia
  • Remote gastrectomy or gastrojejunostomy

39
TREATMENTS OF GASTRIC CANCER
  • ? Surgery (Early or Advanced Cancer)
  • ? Distal tumours which involve the lower
    ½ (sub-total or partial gasterectomy).
  • ? Proximal tumours which involve the
    fundus, cardia or body (total gasterectomy).

40
Surgical Treatment
41
  • TREATMENT
  • SURGERY
  • The only curative tx for gastric cancer
  • Except
  • Cant tolerate abdominal surgery
  • Overwhelming metastasis
  • Palliation is poor w/ non-resective operations
  • GOAL resect all tumors, w/ negative margins
    (5cm) and adequate lymphadenectomy (need for RFS)
  • Enbloc resection of adjacent organ is done if
    needed.

42
  • TREATMENT
  • SURGERY
  • Radical subtotal gastrectomy
  • Standard operation for gastric cancer
  • Organs resected
  • Distal 75 of stomach
  • 2 cm of duodenum
  • Greater lesser omentum
  • Ligation of R L gastric artery and
    gastroepiploic vesels
  • Billroth II gastojejunostomy

43
  • TREATMENT
  • SURGERY
  • Radical subtotal gastrectomy
  • Standard operation for gastric cancer
  • If gastric remnant left is small (lt20) do
    Roux-en-Y reconstruction

44
Endoscopic Resection of Gastric Carcinoma
  • Criteria
  • Tumor lt 2cm in size
  • Node negative
  • Tumor confined on the mucosa
  • Nodes metastasis is lt 1
  • No mucosal ulceration
  • No lymphatic invasions
  • lt3cm tumor

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Treatment of gastric cancer
  • Endoscopic treatment
  • EMR (endoscopic mucosal resection)
  • ablation
  • Surgery
  • Multimodal treatment
  • Neo-adjuvant
  • Adjuvant
  • Palliative treatment

46
Endsocopic mucosal resection
  • T1 mucosal disease
  • Minimal risk of LN metastases
  • Various techniques
  • Specimen obtained

47
Distal Pancreatectomy
  • Associated with marked increase in morbidity
    mortality with or without splenectomy
  • Indications for pancreatectomy
  • Direct invasion of the tail of the pancreas
  • Likelihood of splenic artery nodal involvement

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Surgical Treatment
49
  • ? Inoperable tumours Whenever possible it
    is advisable to do even a limited gastric
    resection. If resection is impossible an
    anterior gastrojejunostomy.

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Indications for Splenectomy
  • If macroscopic disease can be resected the
    operation is potentially curative then en bloc
    splenectomy or pancreaticosplenectomy is
    worthwhile.
  • If it is more palliative then this benefit must
    be weighed against the potential complications of
    splenectomy and more extensive operation

51
  • ? Chemotherapy for gastric cancer
  • (Pre-operatve post-operative)
  • ? Radiotherapy
  • (Pre-intra post-operatively)

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Adjuvant Therapy
  • Rationale is to provide additional loco-regional
    control.
  • Radiotherapy- studies show improved survival,
    lower rates of local recurrence when compared to
    surgery alone.
  • In unresectable patients, higher 4 year survival
    with mutimodal tx, in comparison to chemo alone.

53
Chemotherapy
  • Numerous randomized clinical trials comparing
    combination chemotherapy in the adjuvant setting
    to surgery alone did not demonstrate a consistent
    survival benefit.
  • The most widely used regimen is 5-FU,
    doxorubicin, and mitomycin-c. The addition of
    leukovorin did not increase response rates.

54
Advanced Unresectable Disease
  • Surgery is for palliation, pain, allowing oral
    intake
  • Radiation provides relief from bleeding,
    obstruction and pain in 50-75. Median duration
    of palliation is 4-18 months

55
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

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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.

57
OTHER GASTRIC TUMOURS
  • ? Gastric Lymphomas
  • ? Primary lymphomas of the stomach of
    the non Hodgkins type (NHL).
  • ? The symptoms are similar to those of
  • gastric cancer (adenocarcinoma).
  • ? The diagnosis is made principally from
  • endoscopic examination with biopsy and
  • cytology.
  • ? CT Scanning is important in staging the
  • disease.

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  • ? Treatment
  • - Well-localized disease should be treated
    with resection (surgery) followed by
    radiotherapy or chemotherapy.
  • - Extensive disease by adjuvant chemo-
  • therapy radiotherapy than surgery.

59
  • ? Leiomyosarcoma
  • ? Arise in the stomach representing 1 of
    gastric tumors.
  • ? They may be sessile or pedanculated
    projecting into the gastric lumen or
    extragastrical or both (dumb-bell tumour).
  • ? Presentation due to blood loss anaemia
    or epigastric mass or vague dyspepsia.
  • ? Malignancy is suggested by the size more
    than 5 cm and confirmed by noting increased
    mitosis on histology.

60
Stromal tumours
  • GIST (Gastro-Intestinal Stromal Tumour)
  • Presentation
  • Incidental
  • Bleeding
  • Pathology
  • Blend sheets of spindle cells
  • Previously mistaken for leiomyomata
  • Origin cell interstitial cell of Cahal
  • C-kit ve
  • Actin -ve

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Stromal tumours
  • Prognostic factors
  • Size (gt4cm)
  • Resection margins
  • Mitoses
  • Vacuoles on EUS

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Stromal tumours
  • Surgical Treatment
  • Excision with clear margins
  • No lymphadenectomy required
  • Non surgical treatment
  • Glivec (imatinib)
  • Recurrence / inoperable
  • ? Neoadjuvant / adjuvant

63
  • ? Gastric Carcinoid Tumour
  • ? Are very rare. There is established
    association between atrophic gastritis
    carcinoid pernicious anemia.
  • ? Gastric carcinoids are best treated by local
    resection. If very small by endoscopic
    resection.

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Gastric Carcinoid Tumours
  • lt1 of gastric tumours
  • 4-41 of GIT carcinoid tumours
  • Most ECL/argyrophil cell origin (80)
  • 3 clinico-pathological subtypes
  • Type 1, 2 3

65
Gastric Carcinoid Tumours
  • Type 1 Hypergastrinaemia with Autoimmune
    chronic atrophic gastritis (Type A)
  • Pernicious anaemia
  • Type 2 Hypergastrinaemia with hypertrophic
    gastropathy
  • Zollinger-Ellison syndrome
  • Type 3 Sporadic, no relation to
    hypergastrinaemia

66
Gastric Carcinoid Tumours Rindi et al
67
Type 1 Gastric Carcinoid
  • Type 1 Gastric carcinoid tumours associated
    with Type A Autoimmune Chronic Active Gastritis
  • Autoimmune process leads to destruction and
    gradual atrophy of chief and parietal cells of
    body/fundus - sparing of body/fundic
    neuroendocrine cells
  • Hypochlorhydria or achlorhydria

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Gastric Carcinoid Tumours
  • Hyperplastic precursor sequence
  • Hypergastrinaemia -- Neuroendocrine hyperplasia
    -- Dysplasia -- Neoplasia
  • Pernicious anaemia only present in 20-46 of
    patients (latent effect)
  • Natural history most probably remain
    stationary some regress and some metastasize

69
Results of therapy stomach cancer
  • Surgery with curative intent
  • 42 of patients
  • 5 year survival 60
  • Node positive - 35
  • Node negative - 88

Sue Ling et al (1993) BMJ
70
Multimodal therapy
  • Adjuvant chemotherapy
  • Possible small advantage
  • OR 0.84 (0.74 0.96)
  • Western 0.96
  • Asian 0.58
  • Janunger 2001
  • Neo-adjuvant chemotherapy (ECF)
  • MAGIC trial
  • Surgery /- chemo
  • 503 patients
  • Higher curative resection rate
  • 79 vs 69
  • Better survival at 2 years
  • 48 vs 40

71
Palliative chemotherapy
  • Median survival benefit 3 6 months
  • Combination therapy superior
  • 50 gain improvement in QOL
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