Gastric tumours
This presentation is the property of its rightful owner.
Sponsored Links
1 / 71

GASTRIC TUMOURS PowerPoint PPT Presentation


  • 276 Views
  • Uploaded on
  • Presentation posted in: General

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. ANATOMY :.

Download Presentation

GASTRIC TUMOURS

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


GASTRICTUMOURS

Anatomy of the stomach

Aetiology of Gastric cancer

Types of Gastric cancer

Pathology of Gastric Cancer

Evaluation of Gastric Cancer

Treatment of Gastric Cancer


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.


BLOODSUPPLY:

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.


Anatomy

  • Stomach has five layers:

    • Mucosa

      • Epithelium, lamina propria, and muscularis mucosae*

    • Submucosa

    • Smooth muscle layer

    • Subserosa

    • Serosa


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…


The cause of the disease multistep process but several predisposing factors attributed to cause the disease :

a.Environmente.Atrophic gastritis

b.Dietf.Chronic gastric ulcer

c.Heredityg.Adenomatous polyps

d.Achlorhydriah.Blood group A

i.H. Pyloric colonisation


TYPESOFGASTRICCANCER:

A.Benign Tumours

B.Malignant Tumours


TYPESOFGASTRICCANCER:

A.Benign Tumours

B.Malignant Tumours


THEBENIGNTUMORS:

Although benign tumors can occur in the stomach most gastric tumours are malignant.


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.


PATHOLOGYOFGASTRIC(MALIGNANT)TUMOURS:

 The gastric cancer may arise in the antrum (50%), the gastric body (30%), the fundus or oesophago-gastric juntion (20%).


TypesofMalignantTumours:

a.Adenocarcinoma

b.Leiomyosarcoma

c.Lymphomas

d.Carcinoid Tumours


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)


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


Diffuse

M:F 1:1

Onset Middle Age

5 yr surv overall <10%

Aetiology

Diet

H. pylori

Intestinal

M:F 2:1

Onset Middle Age

5 yr surv overall 20%

Aetiology

Unknown

Blood group A association

H. pylori

Gastric Carcinoma


 Early Gastric Cancer:Defined as cancer whichis 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.


Pathology:

Gastric dysplasia ---> 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%

Gastric Neoplasm:


STAGINGOFGASTRICCANCER:

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)


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)


SPREADOFGASTRICCANCER:

 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


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)


Clinical Manifestation:

  • Paraneoplastic syndromes ( Trousseau’s syndrome – thrombophlebitis; acanthosis nigricans – hyperpigmentation of axilla and groin; peripheral neuropathy)

  • Signs of distant metastasis:

    • Hepatomegally / ascites

    • Krukenbergs tumor

    • Blummers shelf (drop metastasis)

    • Virchow’s node

    • Sister Joseph node (pathognomonic of advances dse)


SUMMARY:

 Often asymptomatic until late stage.

 Marked weight loss

 Anorexia

 Feeling of abdominal fullness or discomfort

 Epigastric mass

Iron Deficiency Anaemia

Left supraclavicular mass (Troisier’s Sign)

Obstructive Jaundice (Secondary in porta

hepatitis)

 Pelvic mass (Krukenberg)


EVALUATIONOFGASTRICCANCER:

History

Clinical Examination

Investigations

The clinical features of gastric cancer may arise from local disease, its complications or its metastases.


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


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.


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.


Investigations for patients with gastric cancer

  • Endoscopy & biopsy

  • Performance status

  • Physiological assessment

    • Cardio-pulmonary function

  • CT chest & abdomen

  • EUS (endoscopic ultrasound)

  • Laparoscopy


CT scanning

  • Technique

    • Spiral CT of chest and abdomen


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.


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

    • Menetrier’s disease

    • Intestinal metaplasia or dysplasia

    • Remote gastrectomy or gastrojejunostomy


TREATMENTSOFGASTRICCANCER:

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).


Surgical Treatment


TREATMENT:

SURGERY:

  • The only curative tx for gastric cancer

  • Except:

    • Can’t 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.


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


TREATMENT:

SURGERY:

Radical subtotal gastrectomy

Standard operation for gastric cancer

If gastric remnant left is small (<20%) do Roux-en-Y reconstruction


Endoscopic Resection of Gastric Carcinoma

Criteria:

  • Tumor < 2cm in size

  • Node negative

  • Tumor confined on the mucosa

    Nodes metastasis is < 1%:

  • No mucosal ulceration

  • No lymphatic invasions

  • <3cm tumor


Treatment of gastric cancer

  • Endoscopic treatment

    • EMR (endoscopic mucosal resection)

    • ablation

  • Surgery

  • Multimodal treatment

    • Neo-adjuvant

    • Adjuvant

  • Palliative treatment


Endsocopic mucosal resection

  • T1 mucosal disease

    • Minimal risk of LN metastases

  • Various techniques

  • Specimen obtained


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


Surgical Treatment


Inoperable tumours: Whenever possible it is advisable to do even a limited gastric resection. If resection is impossible an anterior gastrojejunostomy.


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


Chemotherapy for gastric cancer

(Pre-operatve & post-operative)

Radiotherapy

(Pre-intra & post-operatively)


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.


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.


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


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


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.


OTHERGASTRICTUMOURS:

Gastric Lymphomas:

Primary lymphomas of the stomach of the non Hodgkin’s 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.


 Treatment:

-Well-localized disease should be treated with resection (surgery) followed by radiotherapy or chemotherapy.

-Extensive disease by adjuvant chemo-

therapy & radiotherapy than surgery.


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-belltumour).

Presentation due to blood loss anaemia or epigastric mass or vague dyspepsia.

Malignancy is suggested by the size more than 5cm and confirmed by noting increased mitosis on histology.


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


Stromal tumours

  • Prognostic factors

    • Size (>4cm)

    • Resection margins

    • Mitoses

    • Vacuoles on EUS


Stromal tumours

  • Surgical Treatment

    • Excision with clear margins

    • No lymphadenectomy required

  • Non –surgical treatment

    • Glivec (imatinib)

    • Recurrence / inoperable

    • ? Neoadjuvant / adjuvant


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.


Gastric Carcinoid Tumours

  • <1% of gastric tumours

  • 4-41% of GIT carcinoid tumours

  • Most ECL/argyrophil cell origin (80%)

  • 3 clinico-pathological subtypes:

    • Type 1, 2 & 3


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


Gastric Carcinoid Tumours : Rindi et al


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


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


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


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%

Multimodal therapy


Palliative chemotherapy

  • Median survival benefit 3 – 6 months

  • Combination therapy superior

  • 50% gain improvement in QOL


  • Login