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GASTRIC CA. Ruanto , M.T., Sabalvaro , D.K., Salac , C.N., Salazar, J. References: Harrison’s Principle of Internal Medicine 17 th edition www.cancer.org. EPIDEMIOLOGY. GASTRIC ADENOCARCINOMA Decrease incidence and mortality rates for gastric CA during past 75 years (unclear reasons)

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gastric ca

GASTRIC CA

Ruanto, M.T., Sabalvaro, D.K., Salac, C.N., Salazar, J.

References: Harrison’s Principle of Internal Medicine 17th edition

www.cancer.org

epidemiology
EPIDEMIOLOGY

GASTRIC ADENOCARCINOMA

  • Decrease incidence and mortality rates for gastric CA during past 75 years (unclear reasons)
  • Risk: lower > higher socioeconomic classes
  • Development:
    • Environmental exposure beginning early in life
    • Dietary carcinogens
epidemiology3
EPIDEMIOLOGY

PRIMARY GASTRIC LYMPHOMA

  • Uncommon: <15% of gastric malignancies

~2% of all lymphomas

  • Stomach – most frequent extranodal site for lymphoma
  • Increased in frequency during the past 30 days
  • Detected during the 6th decade of life
epidemiology4
EPIDEMIOLOGY

GASTRIC (NONLYMPHOID) SARCOMA

  • Leiomyosarcomas & GIST: 1-3% of gastric neoplasms
clinical features
CLINICAL FEATURES

ADENOCARCINOMA

  • Asymptomatic - superficial & surgically curable
  • insidious upper abdominal discomfort (vague, postprandial fullness to severe steady pain) - extensive tumors
  • Anorexia with slight nausea
  • Weight loss, nausea & vomiting - tumors of the pylorus
  • dysphagia & early satiety - diffuse lesions originating in cardia
  • No early physical signs
  • Palpable abdominal mass – long-standing growth, regional extension
clinical features6
CLINICAL FEATURES

ADENOCARCINOMA

  • Metastases:
    • intraabdominal lymph nodes
    • supraclavicular lymph nodes
    • Ovary (Krukenberg’s tumor)
    • Periumbilical region (“Sister Mary Joseph node”)
    • Peritoneal cul-de-sac (Blumer’s shelf): palpable on rectal or vaginal examination
  • Malignant ascites
  • Liver – most common site for hematogenous spread of tumor
  • Unusual clinical features: migratory thromboplebitis, microangiopathic hemolytic anemia & acanthosisnigrans
clinical features7
CLINICAL FEATURES

PRIMARY GASTRIC LYMPHOMA

  • Epigastric pain, early satiety & generalized fatigue
  • Ulcerations with ragged, thickened mucosal pattern by contrast radiographs

GASTRIC (NONLYMPHOID) SARCOMA

  • Anterior and posterior walls of gastric fundus
    • most frequently involved
    • Ulcerate and bleed
  • Rarely invade adjacent viscera
  • Do not metastasize to lymph nodes
  • May spread to liver and lungs
diagnosis
DIAGNOSIS
  • Double contrast radiographic examination
        • Simplest procedure – epigastric complaints
        • Helps detect small lesions by improving mucosal detail
        • Stomach should be distended  decreased distensibility may be the only indication of diffused infiltrative carcimoma
  • Gastroscopy
        • Not mandatory if:
            • Radiographic features are typically benign
            • Complete healing can be visualized by x-ray within 6 weeks
            • Follow-up contrast radiograph obtained several months later shows a normal appearance
slide9

DIAGNOSIS

  • Gastroscopic biopsy and brush cytology
          • Should be made as deeply as possible
          • Recommended in all patients with gastric ulcers  to exclude malignancy
          • Malignant ulcers must be recognized before they penetrate into surrounding tissues
          • Rate of cure of early lesions limited to mucosa and submucosa is >80%
surgical treatment
SURGICAL TREATMENT
  • Complete surgical removal of the tumor with resection of adjacent lymph nodes
    • Only chance for cure
    • Possible in <1/3 of patients
  • Subtotal gastrectomy – distal carcinomas
  • Total or near-total gastrectomies – more proximal tumors
  • Extended lymph node dissection – an added risk for complications, do not enhance survival
surgical treatment20
SURGICAL TREATMENT
  • Prognosis depends on the degree of tumor penetration into the stomach wall.
    • Adversely influenced by regional lymph node involvement, vascular invasion, and abnormal DNA content
  • Probability of survival after 5 years
    • ~20% for distal tumors
    • <10% for proximal tumors
    • Recurrences continuing for at least 8 years after surgery
  • For patients whose disease is “incurable” by surgery with no ascites or extensive hepatic or peritoneal metastasis:
    • Resection of the primary lesion should still be offered.
    • Reduction of tumor bulk – best form of palliation; enhance probability of benefit from subsequent therapy
radiation therapy
Radiation Therapy
  • Major role: palliation of pain
    • Gastric adenocarcinoma is a relatively radioresistanttumor.
    • Control of tumor requires doses of irradiation exceeding the tolerance of surrounding structures (eg., bowel mucosa and spinal cord).
  • Survival in the setting of surgically unresectable disease limited to the epigastrium was slightly prolonged when 5-FU was given in combination with radiation therapy.
    • 5-FU: radiosensitizer
pharmacologic therapy
Pharmacologic Therapy
  • Cisplatin + epirubicin & infusional 5-FU or + irinotecan
    • Complete remissions are uncommon.
    • Partial responses in 30-50% of cases are transient.
    • Overall influence on survival has been unclear.
  • Adjuvant chemotherapy alone following complete resection has only minimally improved survival.
  • Perioperativetreatment and postoperative chemotherapy + radiation therapy reduce the recurrence rate and prolongs survival.