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CARCINOMA STOMACH
EPIDEMIOLOGY
90- 95% OF MALIGNANT TUMOURS OF
STOMACH
WORLDWIDE DISEASE - 3% OF CANCER
DEATHS
JAPAN,COLOMBIA,COSTA RICA,
HUNGARY - HIGH INCIDENCE
LOW INCIDENCE –USA,UK,CANADA
EPIDEMIOLOGY
RACIAL FACTORSHIGHER INCIDENCE IN BLACKS,
AMERICAN INDIANS, NORTH
WALES,CHINESE IN INDONANESIA
GENETIC FACTORS – 4% OF
PATIENTS HAVE FAMILY HISTORY
INDIVIDUALS WITH BLOOD GROUP A
HAVE HIGHER INCIDENCE
CARCINOMA STOMACH
PATHOGENESIS
TWO MORPHOLOGIC TYPES
1.INTESTINAL TYPE – ARISE
FROM INTESTINAL METAPLASIA,
MORE COMMON TYPE-ABOVE
50YRS M:F- 2:1
2. DIFFUSE TYPE- ARISE De
NOVO FROM GASTRIC MUCOUS
CELLS. OVER 60 YRS M:F-EQUAL
RISK FACTORS FOR GASTRIC
CARCINOMA
INTESTINAL TYPE
1. DIET
A.NITRITES FROM FOOD, DRINKING
WATER,AS PRESERVATIVES IN PREPARED
MEALS- UNDERGO NITROSATION TO FORM
NITROSAMINES & NITROSAMIDES
B. SMOKED FOOD & PICKLED
VEGETABLES
C. EXCESSIVE SALT INTAKE
PATHOGENESIS OF
INTESTINAL TYPE
D. DECREASED INTAKE OF FRESH
VEGETABLES & FRUITS ANTIOXIDANTS PRESENT IN THESE
FOODS INHIBIT NITROSATION
2. CHRONIC ATROPHIC GASTRITIS
WITH INTESTINAL METAPLASIA
A. INFECTION WITH HELICOBACTOR
PYLORI- MAJOR RISK FACTOR- HOW
?
PATHOGENESIS
THESE PATIENTS DEVELOP SEVERE
GASTRIC ATROPHY,INTESTINAL
METAPLASIA ULTIMATELY
DYSPLASIA & CANCER- CHRONIC
INFLAMMATION- DNA DAMAGING
FREE RADICALS- MUTATIONSHYPERPROLIFERATION NOT
BALANCED BY APOPTOSIS
B.PERNICIOUS ANEMIA
PATHOGENESIS
3.ALTERED ANATOMY
AFTER SUBTOTAL DISTAL
GASTRECTOMY- STUMP
CARCINOMA
4. MENETRIER’S DISEASE –
GASTRIC PIT HYPERPLASIA &
CYST FORMATION
PATHOGENESIS
5. ADENOMAS- SIZE 2cms OR
MORE
PATHOGENESIS
A STEP IN MALIGNANT PROGRESSION
IS APPEARANCE OF GASTRIC
EPITHELIAL DYSPLASIA(GED)-LOW
OR HIGH GRADE.
LOW GRADE IS REVERSIBLE IN 66%
CASES
LOCATION OF GASTRIC CARCINOMA
WITHIN THE STOMACH
PYLORUS & ANTRUM- 50- 60%
CARDIA – 25%
REMAINDER IN THE BODY & FUNDUS
LESSOR CURVATURE- 40%
GREATER CURVATURE – 12%
FAVOURED LOCATION IS THE
LESSOR CURVATURE OF THE
ANTROPYLORIC REGION.
CLASSIFICATION
ON THE BASIS OF DEPTH OF
INVATION & & MACROSCOPIC
GROWTH PATTERN & HISTOLOGIC
SUBTYPE.THE MORPHOLOGIC
FEATURE HAVING
THE GREATEST IMPACT ON CLINICAL
OUTCOME IS THE DEPTH OF
INVASION
EARLY GASTRIC
CARCINOMA
LESION CONFINED TO THE MUCOSA
& SUBMUCOSA,REGARDLESS OF
THE PRESENCE OR ABSENCE OF
PERIGASTRIC LYMPH NODE
METASTASIS
ADVANCED GASTRIC
CARCINOMA
ADVANCED GASTRIC CARCINOMA IS
A NEOPLASM THAT HAS EXTENDED
BELOW THE SUBMUCOSA INTO THE
MUSCULAR WALL.
INTESTINAL TYPE- ADVANCED
GASTRIC CARCINOMA-GROSS
• INTESTINAL TYPE OF
ADENOCARCINOMA CLOSELY
RESEMBLE COLONIC CANCERS –
TEND TO BE
1. POLYPOID
2. FUNGATING – PROTRUDING
LARGER WITH EXTENSIVE
ULCERATION OF THE TOP
INTESTINAL TYPE- ADVANCED
GASTRIC CARCINOMA-GROSS
3. ULCERATED OR EXCAVATED
TYPE
4.COLLOID TYPE
5.DEPRESSED OR FLAT TYPE &
ARE WELL DEMARCATED
6.ULCER CANCER- ?
MACROSCOPIC GROWTH
PATTERNS
EXOPHYTIC TUMOUR( POLYPOID OR
FUNGATING) MAY CONTAIN
PORTIONS OF ADENOMA
DEPRESSED OR FLAT TYPE- LOOK
LIKE EFFACEMENT OF NORMAL
MUCOSAL PATTERN
CARCINOMA STOMACH
ULCERATIVE TYPE
LARGE
EXCAVATING
ULCER WITH
HEAPED UP
MARGINS &
NECROTIC BASE.
MACROSCOPIC GROWTH
PATTERNS
EXCAVATED CANCER MAY MIMIC IN
SIZE & APPEARANCE CHRONIC
PEPTIC ULCERS.MORE ADVANCED
CASES EXHIBIT HEAPED UP MARGINS
MACROSCOPIC GROWTH
PATTERNS
7. DIFFUSELY INFILTRATING TYPE.
A LARGE REGION OF GASTRIC WALL
OR THE ENTIRE STOMACH MAY BE
EXTENSIVELY INFILTRATED BY
MALIGNANCY.
MACROSCOPIC GROWTH
PATTERN
THIS REGID & THICKENED STOMACH
IS TERMED LEATHER BOTTLE
STOMACH OR LINITIS PLASTICA –
SEEN IN DIFFUSE TYPE OF
CARCINOMA.
METASTASIS FROM BREAST & LUNG
MAY GENERATE A SIMILAR PICTURE
MACROSCOPIC GROWTH
PATTERN
ULCERATED CARCINOMAS MAY BE
DISTINGUISHED FROM CHRONIC
GASTRIC PEPTIC ULCER BY BEING
GROSS
• BIGGER,MORE IRREGULAR & HAVING
HEAPED UP OR ROLLED EDGE.
• ANY ENDOSCOPICALLY SUGGESTIVE
LESION IN THE STOMACH SHOULD
HAVE MULTIPLE BIOPSIES TAKEN
FOR PATHOLOGIC
EVALUATION,TAKEN FROM AN EDGE
RATHER THAN BASE.
GROSS FEATURES OF BENIGN &
MALIGNANT GASTRIC ULCERS
•
BENIGN
MALIGNANT
• SIZE
SMALLER
LARGER
• SHAPE
REGULAR
IRREGULAR
• BORDERS OEDEMATOUS HEAPED UP
• MUCOSAL FOLDS RADIATING
• ULCER BED
CLEAN
INTERRUPTED
NECROTIC
HISTOLOGIC(MICROSCOPIC)
CLASSIFICATION
1.WHO CLASSIFICATION –
PAPILLARY,
TUBULAR ,
MUCINOUS &
SIGNET RING TYPES –
EASY TO APPLY & REPRODUCIBLE
BUT HAS NO VALUE IN STUDIES OF
PATHOGENESIS OR ETIOLOGY.
HISTOLOGIC(MICROSCOPIC)
CLASSIFICATION
2.SYSTEM OF LAUREN2 TYPES
INTESTINAL & DIFFUSE – MORE
USEFUL- CORRELATED WELL WITH
ETIOPATHOGENESIS
MICROSCOPIC PICTURE
INTESTINAL TYPE
1. WELL FORMED GLANDULAR
PATTERN
2. MAY HAVE SOLID OR PAPILLARY
AREAS- INDIVIDUAL CELLS ARE
COLUMNAR OR CUBOIDAL WITH A
BASALLY LOCATED NUCLEI.
MICROSCOPICAL PICTUREINTESTINAL TYPE
3. CELLS WITH INTRACYTOPLASMIC
MUCIN ARE UNCOMMON, ALTHOUGH
MUCIN MAY BE SEEN WITH IN THE
GLAND LUMENS
INTESTINAL TYPE CARCINOMA
BRUSH CYTOLOGY OF GASTRIC
CARCINOMA- INTESTINAL TYPE
MICROSCOPICAL PICTUREINTESTINAL TYPE
INTESTINAL TYPE OF
CARCINOMA CAN BE WELL TO
MODERATELY TO POORLY
DIFFERENTIATED.
MORPHOLOGY- DIFFUSE TYPE
GROSS- MORE LIKELY TO HAVE A
PLAQUE LIKE SURFACE
COMPONENT & AN ILL-DEFINED
WIDELY INFILTRATING GROWTHLEATHER BOTTLE STOMACH
(LINITIS PLASTICA).
MORPHOLOGY- DIFFUSE TYPE
MICROSCOPY - COMPOSED OF
INDIVIDUAL & SMALL GROUPS OR
CORDS OF CELLS. STROMA IS
FIBROUS OR MUCOID.
MANY TUMOUR CELLS CONTAIN
MUCIN DROPLETS GIVING A SIGNET
RING CONFIGURATION.
SIGNET RING CELL
CARCINOMA
MICROSCOPY
16 % OF CARCINOMA STOMACH ARE
UNCLASSIFIED OR OF MIXED TYPE.
PROGNOSTIC FACTORS
OVERALL PROGNOSIS OF
GASTRIC CARCINOMA IS POOR.
WITH AN AVERAGE 5 YEAR
SURVIVAL OF ONLY 10 – 15 %.
PROGNOSTIC FACTORS
ADVERSE PROGNOSTIC
FACTORS ARE
1. AGE OLDER THAN 70 YRS.
PROGNOSTIC FACTORS
2. CEA ANTIGEN MORE THAN 10ng
/ml
3. CA19 -9 MORE THAN 37
MICROGRAM/ml
PROGNOSTIC FACTORS
4. SURVIVAL IS HIGH WITH INTESTINAL
TYPE BECAUSE THEY ARE GENERALLY
PRESENT EARLIER WITH LESS ADVANCED
DISEASE. WHEN MATCHED STAGE FOR
STAGE NO DIFFERECE IN SURVIVAL
BETWEEN THE TWO TUMOUR TYPES
5. STAGE OF THE TUMOUR
SPREAD
THREE MODES OF SPREAD
1. LYMPHATIC –LYMPH NODE
2. BLOOD STREAM
3. TRANSPERITONEAL ROUTE
LYMPHATIC SPREAD
LYMPH NODES ALONG GREATER &
LESSER CURVATURE 70% OF
RESECTED SPECIMENS
EARLY SPREAD VIA THORACIC DUCT
LATER SPREAD TO PORTA HEPATIS,
PARAAORTIC NODES
LYMPHATIC SPREAD
SOMETIMES THORACIC DUCT TO LEFT
SUPRACLAVICULAR NODES VIRCHOW
NODES.
SPREAD
LATER LUNGS, BRAIN,
BONES,KIDNEYS ,ADRENALS &
OTHER DISTASNT SITES ARE
INVOLVED BY HAEMATOGENOUS
ROUTE
TRANSRPERITONEAL SPREAD –
INTRAABDOMINAL SITESPARTICULARLY PELVIS , OVARIES.
SPREAD
• KRUKENBERG’S TUMOUR IS
BILATERAL OVARIAN
METASTASES OF A SIGNET
RING CARCINOMA.
DIAGNOSIS
• STAINING WITH ALCIAN BLUE WITH
PAS STAIN HELPS IN DIAGNOSIS ON A
BIOPSY
• BRUSH CYTOLOGY OF THESE
LESIONS-85 % ACCURATE.
EARLY GASTRIC
CARCINOMA
PRIMARY GROWTH IS CONFINED TO
THE MUCOSA OR SUBMUCOSA OF
THE STOMACH, MAY BE ASSOCIATED
WITH LOCAL LYMPH NODE
METASTASES OR EVEN HEPATIC
METASTASES.
MOST ARE CURABLE BY SURGERY.
MORPHOLOGY
EARLY GASTRIC CARCINOMA
SUBCLASSIFIED INTO
• FLAT
• ELEVATED
• PROTRUDED
• DEPRESSED
• EXCAVATED
• COMBINED FORMS
EARLY GASTRIC
CARCINOMA
MORPHOLOGY
• HISTOLOGY OF EARLY GASTRIC
CARCINOMA IS SIMILAR TO THAT OF
ADVANCED CANCER WITH
INTESTINAL, DIFFUSE OR MIXED
FORMS.
TNM STAGING OF GASTRIC
CARCINOMA.
Tis- CARCINOMA IN SITU
T1 – INVASION OF LAMINA PROPRIA
OR SUBMUCOSA
T2- INVASION OF MUSCULARIS
PROPRIA OR SUBSEROSA
TNM STAGING OF GASTRIC
CARCINOMA.
T3- TUMOUR PENETRATES VISCERAL
PERITONIUM
T4 – TUMOUR INVADES ADJACENT
STRUCTURES
TNM STAGING CONTINEUD
N0 -- NO REGIONAL NODES
INVOLVED
NI – 1-6 REGIONAL NODES
INVOLVEMENT
TNM STAGING CONTINEUD
N2 – 7- 15 REGIONAL NODES
INVOLVEMENT
N3 – MORE THAN 15 REGIONAL NODE
INVOLVEMENT
TNM STAGING OF GASTRIC
CARCINOMA- CONTI
• M0 - NO DISTANT METASTASIS
• M1- DISTANT METASTASIS PRESENT
TNM STAGING
STAGE O - Tis,N0 ,M0
STAGE IA -T1N0M0
IB - T2N0M0
T1N1M0
TNM STAGING
IIA - T3N0M0
T2N1M0
T1N2M0
1IB - T4aN0M0
T3N1M0
T2N2M0
T1N3M0
TNM STAGING
1IIA -T4aN1M0
T3N2M0
T2N3M0
IIIB –T4b N0M0
T4b N1M0
T4a N2 M0
T3 N3 M0
TNM STAGING
IIIC - T4bN2M0
T4bN3M0
T4aN3M0
IV
Any T Any N M1