CARCINOMA STOMACH

CARCINOMA STOMACH PROF.DR.V.SHRUTHI KAMAL INCIDENCEGLOBAL STATISTICS 640600 MEN 349000 WOMEN

50% adavanced carcinoma

CA CANCER J.CLIN 2011

Distal cancer Increase in proximal cancers

Incidence remains high in Japan

Their cure rates better due to screening/ survellance/early detection

AgeAverage age of onset 55 yrs Etiology Diffuse cancer Proximal & hereditary

Intestinal type Distal cancers younger Endemic/ inflammatory changes with Helicobacter pylori infection DIET Linked to High ingestion of Redmeat/cabbage/spices/fish/smoked Salt preserved/high carohydratesLow ingestion of fruits vegetables Fat /protein/vitamins A,C,EGastric Cancer Dietary/Lifestyle FactorsCarl-McGrath S, et al. Cancer Therapy (2007).

Helicobacter pylori infectionIncreased riskHP organism found in 89% intestinal type/32% with diffuse type Trials in eradicating HP infection Heredity & Race African/Asian/Hispanic American >riskWhites< riskAnemia pernicious anemia3to18 times > risk Achlorhydria

Atrophic gastritisPrevious Gastric resectionGastric stump ca > 15 to 20 yrs Alakaline bile/dysplasia of gastric ca/ elevated gastrin levels > carry poor prognosis Mucosal dysplasia Grade I to IIIHigh grade dysplasia >marker for future gas .caIntestinal metaplasia/ replacement of Glandular epithelium> intestinal typeGastric Cancer Correa Sequence- pathophysiology

Vogelgram of CRChttp://www.hopkinscoloncancercenter.org

Increasing riskNormalChronic gastritisMucosal atrophyIntestinal metaplasiaIntestinal-type carcinomaDysplasiaPotentially reversibleNot HGDHartgrink HH, et al. Lancet (2009). Gastric polypsFAP ( Familial adenomatous polyposis)Have > incidence of gas .ca/advised endoscopy/ survellenceHyper plastic>do not have malig.potential Chronic gastritisAtrophic gastritis( autoimmune)

Hypertrophic gastritis Menetriers Other risk factors> 50 yrsBlood group ALower socio economic statusAlcoholSmokingObesity HistologyAdeno ca >95%

Leiomyo sarcomaLymphomasSquamous ca >5%Carcinoid Other risk factors contdE cadheringene mutation

HNPCCLIFraumenEB virus Pathology Gross types> cauliflower ulcerative Leather botttle (linitis plastica) Laurens Intestinal type(53%) Good prognosis HP infectionDiffuse type(33%) Bld group A,Familial, signet ring,poor differentiation , younger bad prognosisJapanese classificationEarly gastric > mucosa+ submucosa+ or - nodes1 protruded cure rate >95%2 superdicial3 Excavated

Advanced gastric ca Muscularis+serosa + or nodes Borrmans classificationI single polypoidII ulcerated ca + clear marginIII ,, ,, ,, + with out clear marginIV diffuse & V unclassified

MINGS classificationExpandingInfiltrativeWHO Histological( Microscopic)Adeno ca>papillary,tubular mucinous ,signetAdenosuamousSquamousundifferentitedSiewert classifiaction Proximal gas .caTypeI Ca of GE ( Barrets)TypeII With in 2 cms Squamo columnar juncTypeIII Subcardial Location of cancersDistal >40%Proximal>35%Body>25% SpreadLocal Ulcerative> gsatric wall> serosa schirrous>submucosa/muscularisLymphatic Virchows node ( left supraclavicular )Left axillary (Irish node)Blood spread>liver 40%Lung 40%Sclerotic bone mets/carcinomatous meningitis contdPeritoneum 10% seedling of peritoneal surfacesUmbilicus/falciform(sis Mary joseph nodule)Krukenberg>mets to ovaryBlumer shelf ( rectal shelf in men)Paraneoplastic syndromePolymyosistisDementiaVenous thrombosisEctopic cushingLeser Trelat sign( seborheic keratosis)Acanthosis Diagnosis Anorexia/early satiety/dyspepsiaDyspagia/weakness/Abdominal pain>60%Weight loss>50%Nausea vomiting>40%Palpable mass>30%Haemetemis/ malena>25% InvestigationsCBC/LFT/Chest x-rayEGD( esophagogastroduodenoscopy)USG/EUS(endo ultrasound)CT Diagnostic lap StagingTNM Tx cant be assessed T0 No eveidence of tumour Tis in situ T1 lamina propria or submucosa T2 a muscularis propria T2 binvades subserosa T3 invades serosa T4 adjacent structure

Gastric Cancer Staging SystemsTNM: most important clinical prognostic factor

http://www.hopkins-gi.org

http://www.medscape.com/viewarticle/543068_3 NodesNx cant be assessedNo no nodesN1 1-6 nodesN2 7-15 nodesN3 > 15 nodes MeatastasisMx Mets cant be assessed

Mo No mets

M1 distant mets ManagementSurgery > Curative 1 Endoscopic mucosal resection 2 Subtotal gastrectomy distal 2cm & proximal 5 cm clearance(Billroth II)3 Total gastrectomy (Roux en y) Inoperable tumours

Multiple mets liverExtensive invovolment adjacent organsSMV/SMA Carcinomatosis peritonei ResectionR0 resection > No residual diseaseR1 >microscopic residual diseaseR2> Macroscopic residual diseaseR3> unresectable Nodal stationsFirst tier nodes 1-6 nodesSecond tier nodes 7-11 nodesThird tier nodes 12-18 nodesD1 dissection nodes are N0 (3-6)D2 dissection(N1) 1-11 removedD3dissection(N2)paraaortic hepatodudenal D4 1-18 stationsSurgery -contd PalliationPalliative resectionPalliative by pass Anterior Gastrojejunostomy/feeding jejunostomyLaser ablation/ stentingPain relief ChemotherapyAdjuvant chemo therapy 5 FU225mg/m2/days 1-5/1-21 Epirubicin50mg/m2 day1 Cisplatin 60mg/m2/day1Chemo for advanced caECF epirubicin/5 FU/Doxorubicin

EOX epirubicin/0xaliplatin/capecitabine

DCF Docetaxel/cisplatin/5FU Radio therapy-RoleHelpful in palliation for unrsectable tumors(4000cgy 4wks)IORT (tumour bed) PrognosisEarly 5 yr survival 70- 90%Advanced ca less than 20%Recurrence with in 3 yrsGastric lymphomaPrimary- elderly/NHL-B cell typeMucosal associated lymphoid tissue(MALTOMA)/H.pyloriLoss of appetite/pain abdomen/wt lossMass abdomenAssociated SLE/HIV/Ch gastritis etc complicationsObstructionPerforationBleeding metastasistreatmentTreat HP infectionSurgery for obstructionChemo same as NHLGIST-gastroinestinal stromal tumorNon epithelial /equal sex incidence50-70 yrsArises from interstitial cell of cajalTreat surgeryChemo sunitinibimatinib

THANK YOU