Case Presentation By

Dr Saleem

Scenario

50 years male with mass epigastrium moving with respiration, associated with vomiting, wt loss for two months

O/E : Left supraclavicular node palpable

Provisional Diagnosis

Ca Stomach

Differential Diagnosis

• Ca transverse colon• Ca lt lobe of liver• Ca gall bladder

History

• Age 50 years

• Sex Male

• Duration 02 months

• Nausea vomiting

History

• Epigastric Discomfort,Dyspepsia

• Dysphagia

• Wt loss anorexia and early satiety

Contd:

• Haemetemesis

• Malena

• Altered Bowel habbits

• Bleeding P/R

Contd:• Shortness of breath

• Juandice

• Smoking

• Past history

• Family history

Physical Findings

GPE• Pallor

• Lymph nodes Lt Supraclavicular (virchow) Ant Axillary (irish nodes) Cervical lymph nodes

Contd:

• Trousseau,s sign Thrombophelbitis

• Acanthosis Nigricanus Hyperpigmentation

Abdomen

• Mass epigastrium moves with respiration hard non tender irregular seperate from liver succussion splash

Contd:

• Periumblical metastasis Sister Mary Joseph nodule

• Hepatomegaly• Pelvic Masses (Krukenberg tumor)

• Ascites

• Plueral effusion

Title

• DRE Blumer shelf Hard nodularity extraluminaly and anteriorly also called ,Drop metastasis:

Investigations

Baseline Goal to assist for optimal therapy• CBC

• LFT,s

• Stool for occult blood

Diagnostic workup

• Upper GI endoscopy 95 % accuracy Tissue diagnosis Ulcerated lesion (take 6 biopsies around the lesion)

Contd:

• Double contrast upper GI series And Barium swallow

75% accuracy

for obstructive lesions only

Staging Investigations

• Endoluminal U/S Accuracy for tumor penetration involvement of adjacent structures Lymph nodes involvement

Operater dependent

Contd:

• Chest X ray lung mets plurel effusion

• U/S abdomen liver mets

Contd:

• CT scan Abdomen and Pelvis loccaly advanced disease Metastasis Extra regional lymphadenopathy

• PET Scan To determine sites of unexpected metastasis

Contd:

• Staging Laproscopy To determine possibilty of curitive lesion look for peritoneal and hepatic mets

Staging

Primary tumorTx- cannot be assessedT0- no evidenceTis- carcinoma in situ, no invasion of laminaT1- invades lamina propria or submucosaT2- invades muscularis or subserosaT3- penetrates serosa, no adjacent structureT4- invades adjacent structures

Regional lymph nodes

NX- cannot be assessed

N0- no nodes

N1- mets in 1-6 regional nodes

N2- mets in 7-15 regional nodes

N3- mets in more than 15 regional nodes

Distant Metastasis

MX- cannot be assessed M0- no distant metastases M1-distant metastases

Stages• * Stage 0 - Tis, N0, M0• * Stage IA - T1, N0 or N1, M0• * Stage IB - T1, N2, M0 or T2a/b, N0, M0• * Stage II - T1, N2, M0 or T2a/b, N1, M0 or T2, N0,

M0 • * Stage IIIA - T2a/b, N2, M0 or T3, N1, M0 or T4, N0,

M0• * Stage IIIB - T3, N2, M0• * Stage IV - T1-3, N3, M0 or T4, N1-3, M0, or any T,

any N, M1

Title

Stage 4

Title

Treatment

• Surgery is the only curative treatment for gastric cancer.

• It is the best palliation

• provides the most accurate staging.

Exceptions

• patients who cannot tolerate an abdominal operation, and

• patients with overwhelming metastatic disease.

Goal of Treatment

• resection of all tumor

• all margins (proximal, distal, and radial) should be negative and an adequate lymphadenectomy performed

• negative margin of at least 5 cm

Subtotal gastrectomy

• standard operation for gastric cancer is radical subtotal gastrectomy

Lower radical partial gastrectomy

• carcinoma of the lower third of the stomach.• ligation of the left and right gastric and

gastroepiploic arteries at the origin• en bloc removal of the distal 75% of the

stomach, including the pylorus and 2 cm of duodenum

• the greater and lesser omentum, and all associated lymphatic tissue

Reconstruction

• Reconstruction is usually by Billroth II gastrojejunostomy,

• if a small gastric remnant is left (<20%), a Roux-en-Y reconstruction is considered.

Esophagogasrectomy

growth involving the cardia and gastroesophageal junction

Upper radical partial gastrectomy

• Growths of upper third

Reconstruction• esophagogastrostomy • Pyloroplasty • An isoperistaltic jejunal interposition (Henley

loop) between the esophagus and antrum could be considered.

Total Gastrectomy

• Survival similar compared with subtotal gastrectomy

• Complications higher

• Total gastrectomy with jejunal pouch/ esophageal anastomosis may be the best operation for patients with proximal gastric adenocarcinoma ,linitis plastica

Reconstruction

Lymphadenectomy

The extent of resection is described as • D1. Limited Lymphadenectomy. All N1 Nodes

removed en bloc with the stomach

• D2. Systematic Lymphadenectomy. N1 & N2 nodes en bloc with stomach

• D3. Extended Lymphadenectomy. A more radical en bloc resection including N3 nodes

Extent of lymphadenectomy

• Two randomized trials compared D1 with D2 lymphadenectomy in patients who were treated for curative intent.

• postoperative morbidity (43% versus 25%) and mortality (10% versus 4%) were higher in the D2 group.

• Drawback

Recommended

• A pancreas and spleen-preserving D2 lymphadenectomy

Carcinoma upper third

Carcinoma middle third

Carcinoma lower third

Post op complications

Early complications

• Paralytic ileus.• Leakage from suture line.• Leakage from duodenal stump.• Acute Cholycystitis, Pancreatitis• Stomal obstruction.

Title

Late complications

• Early Dumping syndrome • Late dumping syndrome.• Bilious vomiting.• Gastric stump cancer• Vit B12 deficiency • Osteoporosis

Adjuvant Therapy

• Rationale behind radiotherapy is to provide additional local-regional tumor control.

• Adjuvant chemotherapy is used either as a radiosensitizer or as definitive treatment for presumed systemic metastases.

Adjuvant Radiotherapy• lower rates of local recurrence in patients who

received postoperative radiotherapy than in those who underwent surgery alone

(British stomach cancer study group)

• Improved survival (mayo clinic randomized patients)

Intra operative radiotherapy

• allows for a high dose to be given in a single fraction while in the operating room so that other critical structures can be avoided.

• Stage 3 and 4

• Median survival (21 months vs 10 months ) with IORT

Adjuvant Chemotherapy

• No consistent survival benefit.

• Epirubicin . 5 florouracil ,cis platinium (ECF)

• Combination of chemoradio therapy has better outcome

Neo adjuvant chemotherapy

• downstaging of disease to increase resectability,

• decrease micrometastatic disease burden prior to surgery

• allow patient tolerability prior to surgery• determine chemotherapy sensitivity• reduce the rate of local and distant

recurrences, and ultimately improve survival.

Palliative Care

• radiotherapy provides relief from bleeding, obstruction, and pain in 50-75%

• wide local excision, partial gastrectomy, total gastrectomy, simple laparotomy, gastrointestinal anastomosis, and bypass for food intake or pain relief

Summary