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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


Anatomy of the stomach

Aetiology of Gastric cancer

Types of Gastric cancer

Pathology of Gastric Cancer

Evaluation of Gastric Cancer

Treatment of Gastric Cancer



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


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.



  • Stomach has five layers:

    • Mucosa

      • Epithelium, lamina propria, and muscularis mucosae*

    • Submucosa

    • Smooth muscle layer

    • Subserosa

    • Serosa



 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.


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


A.Benign Tumours

B.Malignant Tumours

Types of gastric cancer1


A.Benign Tumours

B.Malignant Tumours

The benign tumors


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

Gastric tumours

The benign groups includes:-

1.Non-neoplastic gastric polyps


3.Neoplastic gastric polyps

4.Smooth muscles tumours benign


5.Polyposis Syndrome (eg:- Polyposis coli,

Juvenile polyps and P.J. Syndrome)

6.Other benign tumours are fibromas, neurofibromas, aberrat pancreas and


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%).

Types of malignant tumours





d.Carcinoid Tumours

Gastric tumours

The macroscopic forms of gastric cancers are

classified by (Bormann classification) into:-

1.Polypoid or Proliferative



4.Diffuse Infiltrating (Linnitus-


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


M:F 1:1

Onset Middle Age

5 yr surv overall <10%



H. pylori


M:F 2:1

Onset Middle Age

5 yr surv overall 20%



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


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


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


    M0 No distant metastasis

    M1 Distant metastasis (may be further specified

    according to size of occurrence)

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)


3.Blood (Haematogenous)


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)



 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


 Pelvic mass (Krukenberg)

Evaluation of gastric cancer



Clinical Examination


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



A.Upper gastero intestinal endoscopy

with multiple biopsy and brush



CT Scan of the chest and abdomen

USS upper abdomen

Barium meal

C.Diagnostic laparoscopy

Gastric tumours


  • UGIS (double contrast)

  • Endoscopy (Biopsy / Ultrasound)


    • 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.



  • 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



  • 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


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



  • 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



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



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


  • 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)


(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.



  • 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



  • 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



  • 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


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


CT Scanning is important in staging the


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


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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