Lecture 5 Ppt

8/6/2019 Lecture 5 Ppt

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Cancer StomachCancer Stomach

Dr; Omar FaroukDr; Omar FaroukLecturer of Surgical Oncology & BreastLecturer of Surgical Oncology & Breast

Oncology CenterOncology Center -- MansouraMansoura UniversityUniversityIntercollegiate MRCS (England)Intercollegiate MRCS (England)


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GastricGastric NeoplasiaNeoplasia

BenignBenign

Gastric polypsGastric polyps common but usually not neoplastic(hyperplastic polyps. Hamartomas, ectopic pancreas)

AdenomasAdenomas (occur but are rare)

MalignantMalignant

GastricGastric AdenocarcinomaAdenocarcinoma Gastric LymphomaGastric Lymphoma

Gastric SarcomaGastric Sarcoma

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PathologyPathology

Epidemiology

Risk Factors

Gross Picture

Microscopy Spread

Staging

Prggnosis

ManagementManagement

Diagnosis

Clinical Presentation

Investigations

Treatment

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The second most common fatalmalignancy in the

world (after lung cancer) Commonest in Far East (Japan)

High mortality unless disease detected early

Male : Female = 2:[email protected]


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PathologyPathology

Gastric Adenocarcinoma (~ 95%)

Squamous Cell Carcinoma

Adenoacanthoma Carcinoid

Gastrointestinal stromal tumors (GISTs)

Lymphoma

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Vast majority are

adenocarcinomas

Arise on background ofchronic gastritis,

intestinal metaplasia,

dysplasia

Most cases advanced at

presentation

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Gross types

Polypoid

Ulcerative

Infiltrative (extreme is

linitis plastica

leather bottle

stomach)

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Japanese classification systemJapanese classification systemfor early gastric cancer (EGC)for early gastric cancer (EGC)

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T1 mucosa & submucosa

Japanese Endoscopic

Classification

Early GastricEarly Gastric

CarcinomaCarcinoma


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BorrmannBorrmann System ofSystem ofAdvanced gastric cancerAdvanced gastric cancer

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Polypoid

Ulcerative

Cauliflower

Infiltrative


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Borrmanns type I adenocarcinoma

protruding polypoid mass in the antrum

Advanced Gastric CancerAdvanced Gastric Cancer


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Borrmanns type II adenocarcinoma

Ulcerative type


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Borrmanns type IV adenocarcinoma

marked infiltrative thickening of the wall, havingthe contour of a leather bottle (linitus plastica)


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Intestinal type(forms glands likecancers of colon

and oesophagus)

Diffuse typedissociated tumour

cells oftencontaining amucinous blob signet ring cells

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Lauren ClassificationLauren Classification

IntestinalIntestinal Environmental

Gastric atrophy,

intestinal metaplasia

Men > women

Increasing inc. w/ age

Gland formation

Hematogenous Spread

Microsatellite instability

APC gene mutations p53, p16 inactivation

APC, adenomatous

polyposis coli

DiffuseDiffuse Blood type A

Women > men

Younger age group

Poorly differentiated,

signet ring cells

Transmural / lymphatic spread

Decreased E-cadhedrin

p53, p16 inactivation

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PRIMARY TUMOR (T)TX Primary tumor cannot be assessed

T0 No evidence of primary tumorTis Carcinoma in situ: intraepithelial tumor without invasion of the lamina propria

TT11 Tumor invades lamina propria or submucosaT2 Tumor invades muscularis propria or subserosa

T2a Tumor invades muscularis propria

T2b Tumor invades subserosa

T3 Tumor penetrates serosa (visceral peritoneum) without invasion of adjacent

structuresT4 Tumor invades adjacent structures

REGIONAL LYMPH NODES (N)

NX Regional lymph node(s) cannot be assessed

N0 No regional lymph node metastasis

N1 Metastasis in 1 to 6 regional lymph nodes

N2 Metastasis in 7 to 15 regional lymph nodesN3 Metastasis in more than 15 regional lymph nodes

DISTANT METASTASIS (M)

M0 No distant metastasis

M1 Distant metastasis

American Joint Committee (AJCC) onCancer Staging ofGastric Cancer, 2002

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Stage Grouping

O Tis N0 M0

IA T1 N0 M0

IB T1 N1 M0T2a/b N0 M0

II T1 N2 M0T2 N1 M0T3 N0 M0

IIIA T2a/b N2 M0T3 N1 M0

T4 N0 M0

IIIB T3 N2 M0

IV T4 N13 M0T13 N3 M0

Any T Any N [email protected]


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Local infiltration (through wall of stomach to

peritoneum, pancreas etc)

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Lymphatic local and

regional lymph nodes

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Blood liver, lungs

Transcoelomic (across

peritoneal cavity). Ofteninvolves ovaries (esp.

signet ring cancer)

Krukenberg tumour.

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Classification ofClassification of

EsophagogastricEsophagogastric

Junction CancersJunction Cancers

Siewert and Stein1998 have developed a classification system for adenocarcinoma of the

esophagogastric junction. Now commonly referred to as the SiewertSiewert classificationclassification,

this system recognizes three distinct clinical entities that arise within 5 cm of the

junction of the tubular esophagus and the stomach:

Type 1adenocarcinoma of the distal esophagus, which usually arises from an area

with specialized intestinal metaplasia of the esophagus (i.e., Barrett's esophagus) and

may infiltrate the esophagogastric junction from aboveType IIadenocarcinoma of the cardia, which arises from the epithelium of the cardia

or from short segments with intestinal metaplasia at the esophagogastric junction

Type IIIadenocarcinoma of the subcardial stomach, which may infiltrate the

esophagogastric junction or distal esophagus from below

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Clinical PresentationClinical Presentation

AsymptomaticAsymptomatic Early (Dyspepsia):Early (Dyspepsia):

Vague epigastric discomfort / indigestion

Pain is constant, non-radiating, unrelieved by food digestion

More advanced diseaseMore advanced disease

Weight lossAnorexia

Fatigue

Emesis

EpigastricEpigastric MassMass Ulcer CancerUlcer Cancer GI bleedingGI bleeding ObstructionObstruction Occult presentationOccult presentation

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Clinical PresentationClinical Presentation

Physical signsPhysical signs latelate

Assoc. w/ locally advanced orAssoc. w/ locally advanced or metsmets

Palpable abdominal massPalpable abdominal mass

PalpablePalpable supraclavicularsupraclavicular (Virchows) LN(Virchows) LN PalpablePalpable periumbilicalperiumbilical (Sister Mary Josephs)(Sister Mary Josephs)

LNLN

PeritonealPeritoneal metsmets palpable by rectal exampalpable by rectal exam

((BlumersBlumers shelf)shelf) Palpable ovarian mass (Palpable ovarian mass (KrukenbergsKrukenbergs tumor)tumor)

S/S/SxSx ofof hepatomegalyhepatomegaly

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InvestigationsInvestigations

Endoscopy:Endoscopy:VisualizationVisualization

BiopsyBiopsyPalliationPalliation

Laser ablationLaser ablation

DilatationDilatation

TumorTumor stentingstenting

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Endoscopicclassic grossappearance ofbenign ulcer

1) relatively small

2) the radiatingrugal folds extendnearly all the wayto the margins ofthe base.


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Malignant

Ulcer


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EUSEUS-- Aid in stagingAid in staging

gastric wall tumor invasiongastric wall tumor invasion LN statusLN status

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Benign Gastric ulcer niche

Contrast imaging (Barium meal)

Malignant Gastric ulcer



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bariumexamination shows

irregular mucosalnodularity (white

arrows) multiple small

ulcerations (blackarrows) of the

antrum.


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CT scan of abdomenCT scan of abdomen Pelvic CT for women CT chest for proximal gastric

cancer

Limitations

< 5 mm mets liver/peritoneum

Staging for LN mets 25 86 %

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Diagnostic LaparoscopyDiagnostic Laparoscopy

evaluate peritoneal mets

Cytology of peritoneal fluid / peritonealCytology of peritoneal fluid / peritoneallavagelavage

+ finding poor prognosis

CBC, Routine preoperative lab.CBC, Routine preoperative lab.

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Other InvestigationsOther Investigations


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Japanese Treatment ofJapanese Treatment ofEarly Gastric Cancer (TEarly Gastric Cancer (T11):):

Endoscopic ResectionEndoscopic Resection

((MucosectomyMucosectomy)) Photodynamic TherapyPhotodynamic Therapy

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TreatmentTreatment


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Japanese Treatment ofJapanese Treatment ofEarly Gastric Cancer (T1):Early Gastric Cancer (T1):

Endoscopic ResectionEndoscopic Resection

((MucosectomyMucosectomy)) Photodynamic TherapyPhotodynamic Therapy

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TreatmentTreatment


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Operable Operable RadicalRadical

GastrectomyGastrectomy

(R(R11 or Ror R22))++ ReanastmosisReanastmosis //

ReconstructiveReconstructive

pouchpouch

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TreatmentTreatment

Extent of resection in gastric lymphadenectomy,

based on location of the primary cancer


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Distal SubtotalDistal SubtotalRadicalRadical GastrectomyGastrectomy

Subtotal / TotalSubtotal / TotalRadicalRadical GastrectomyGastrectomy

Proximal SubtotalProximal SubtotalRadicalRadical GastrectomyGastrectomy


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TreatmentTreatment

Inoperable PalliativeInoperable Palliative tttttt Palliative resectionPalliative resection

BypassBypass

FeedingFeeding JeujonostomyJeujonostomy

Radioresistant

Less chemotherapy response


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FutureFuture


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THANKTHANK

YOUYOU

Omar FaroukOmar FaroukLecturer of Surgical Oncology

Oncology Center. Faculty of Medicine. Mansoura University


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Lecture 5 Ppt

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