Gastric tumours
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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 :.

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Gastric tumours

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

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.


Blood supply

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.


Anatomy1

Anatomy

  • Stomach has five layers:

    • Mucosa

      • Epithelium, lamina propria, and muscularis mucosae*

    • Submucosa

    • Smooth muscle layer

    • Subserosa

    • Serosa


Aetiology

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…


Gastric tumours

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


Types of gastric cancer

TYPESOFGASTRICCANCER:

A.Benign Tumours

B.Malignant Tumours


Types of gastric cancer1

TYPESOFGASTRICCANCER:

A.Benign Tumours

B.Malignant Tumours


The benign tumors

THEBENIGNTUMORS:

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


Gastric tumours

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.


Pathology of gastric malignant tumours

PATHOLOGYOFGASTRIC(MALIGNANT)TUMOURS:

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


Types of malignant tumours

TypesofMalignantTumours:

a.Adenocarcinoma

b.Leiomyosarcoma

c.Lymphomas

d.Carcinoid Tumours


Gastric 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)


Gastric tumours

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


Gastric carcinoma

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


Gastric tumours

 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.


Gastric neoplasm

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:


Staging of gastric cancer

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

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)


Spread of gastric cancer

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


Gastric tumours

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)


Gastric tumours

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

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)


Evaluation of gastric cancer

EVALUATIONOFGASTRICCANCER:

History

Clinical Examination

Investigations

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


Investigations

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


Gastric tumours

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

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

Investigations for patients with gastric cancer

  • Endoscopy & biopsy

  • Performance status

  • Physiological assessment

    • Cardio-pulmonary function

  • CT chest & abdomen

  • EUS (endoscopic ultrasound)

  • Laparoscopy


Ct scanning

CT scanning

  • Technique

    • Spiral CT of chest and abdomen


Laparoscopy

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

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


Treatments of gastric cancer

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

Surgical Treatment


Gastric tumours

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.


Gastric tumours

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


Gastric tumours

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

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

Treatment of gastric cancer

  • Endoscopic treatment

    • EMR (endoscopic mucosal resection)

    • ablation

  • Surgery

  • Multimodal treatment

    • Neo-adjuvant

    • Adjuvant

  • Palliative treatment


Endsocopic mucosal resection

Endsocopic mucosal resection

  • T1 mucosal disease

    • Minimal risk of LN metastases

  • Various techniques

  • Specimen obtained


Distal pancreatectomy

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 treatment1

Surgical Treatment


Gastric tumours

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


Indications for splenectomy

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


Gastric tumours

Chemotherapy for gastric cancer

(Pre-operatve & post-operative)

Radiotherapy

(Pre-intra & post-operatively)


Adjuvant therapy

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

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

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

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

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.


Other gastric tumours

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.


Gastric tumours

 Treatment:

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

-Extensive disease by adjuvant chemo-

therapy & radiotherapy than surgery.


Gastric tumours

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

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 tumours1

Stromal tumours

  • Prognostic factors

    • Size (>4cm)

    • Resection margins

    • Mitoses

    • Vacuoles on EUS


Stromal tumours2

Stromal tumours

  • Surgical Treatment

    • Excision with clear margins

    • No lymphadenectomy required

  • Non –surgical treatment

    • Glivec (imatinib)

    • Recurrence / inoperable

    • ? Neoadjuvant / adjuvant


Gastric tumours

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

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 tumours1

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

Gastric Carcinoid Tumours : Rindi et al


Type 1 gastric carcinoid

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 tumours2

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

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


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%

Multimodal therapy


Palliative chemotherapy

Palliative chemotherapy

  • Median survival benefit 3 – 6 months

  • Combination therapy superior

  • 50% gain improvement in QOL


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