Download 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
GASTRIC ADENOCARCINOMA
 Decrease incidence and mortality rates for
gastric CA during past 75 years (unclear
reasons)
 Risk: lower > higher socioeconomic classes
 Development:

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Environmental exposure beginning early in life
Dietary carcinogens
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
GASTRIC (NONLYMPHOID) SARCOMA
 Leiomyosarcomas & GIST: 1-3% of gastric
neoplasms
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
ADENOCARCINOMA
 Metastases:
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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 & acanthosis nigrans

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

 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

 Gastroscopic
 Should
biopsy and brush cytology
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%
Stage
TNM
No. of Cases %
Features
5 year survival, %
0
TisN0M0
Node negative;
Limited to mucosa
1
90
IA
T1N0M0
Node negative;
Invasion of lamina propria or
submucosa
7
59
IB
T2N0M0
Node negative;
Invasion of muscularis propria
10
44
II
T1N2M0
T2N1M0
Node positive; invasion beyond
mucosa but within wall
17
29
T3N0M0
Node negative, extension
through wall
IIIA
T2N2M0
T3N1-2M0
Node positive; invasion of
muscularis propria or through
wall
21
15
IIIB
T4N0-1M0
Node negative; adherence to
surrounding tissue
14
9
IV
T4N2M0
Node positive; adherence to
surrounding tissue
30
3
T1-4N0-2M1
Distant metastases
H. Pylori
infection
• a major cause of stomach cancer, especially cancers in the
lower (distal) part of the stomach.
• may lead to inflammation (chronic atrophic gastritis) and
pre-cancerous changes of the inner lining of the stomach
• Stomach cancer is more common in men than in women.
Gender
Aging
• There is a sharp increase in stomach cancer after the age
of 50.
• Most people diagnosed with stomach cancer are in their
late 60s, 70s, and 80s.
Reference: Harrison’s Principles of Internal Medicine, 17th ed.
www.cancer.org
Ethnicity
Diet
• It is most common in Asian/Pacific Islanders.
• An increased risk of stomach cancer is seen with diets
containing large amounts of smoked foods, salted fish
and meat, and pickled vegetables.
• Nitrates and nitrites are substances commonly found in
cured meats. They can be converted by certain bacteria,
such as H. pylori, into compounds that have been found
to cause stomach cancer in animals.
• On the other hand, eating fresh fruits and vegetables
that contain antioxidant vitamins (such as A and C)
appears to lower the risk of stomach cancer.
Reference: Harrison’s Principles of Internal Medicine, 17th ed.
www.cancer.org
Tobacco
use
• Smoking increases stomach cancer risk,
particularly for cancers of the upper
portion of the stomach closest to the
esophagus.
• The rate of stomach cancer is about
doubled in smokers.
Obesity
• Being very overweight or obese has
emerged as a possible cause of cancers of
the cardia (the part of the stomach nearest
the esophagus), but the strength of this link
is not yet clear.
Reference: Harrison’s Principles of Internal Medicine, 17th
ed.
Previous
stomach
surgery
• This may be because it allows more nitrite-producing
bacteria to be present. Also, acid production goes down
after ulcer surgery, and there may be reflux (backup) of
bile from the small intestine into the stomach.
• The risk continues to increase for as long as 15 to 20
years after surgery.
• Certain cells in the stomach lining normally make
intrinsic factor (IF), which is a substance needed to
absorb vitamin B12 from foods.
Pernicious • People without enough IF may end up with a vitamin B12
deficiency, which affects the body's ability to make new
anemia
red blood cells.
Menetrier
disease
• a condition in which excess growth of the stomach lining
leads to the formation of large folds in the lining and to
low levels of stomach acid.
• Because this disease is very rare, the exact increase in
the risk of stomach cancer is not known.
Reference: Harrison’s Principles of Internal Medicine, 17th
ed.
• Hereditary diffuse gastric cancer is an inherited
condition that greatly increases the risk of
developing stomach cancer.
• This condition is quite rare, but the lifetime
stomach cancer risk among affected people is about
Inherited cancer
70% to 80%.
syndromes
• Researchers recently discovered the gene (Ecadherin/CDH1) responsible for this condition.
• Hereditary non-polyposis colorectal cancer (HNPCC,
also known as Lynch syndrome) and familial
adenomatous polyposis (FAP) are also inherited
genetic disorders. They cause a greatly increased
risk of getting colorectal cancer and a slightly
increased risk of getting stomach cancer in family
members who have these gene mutations.
Inherited cancer
• People who carry mutations of the inherited breast
syndromes
cancer genes BRCA1 and BRCA2 may also have a
higher rate of stomach cancer.
Reference: Harrison’s Principles of Internal Medicine, 17th ed.
www.cancer.org
• For unknown reasons, individuals with Type A blood have
an increased risk of developing gastric cancer.
Type A blood
Family history of
gastric cancer
Epstein-Barr
infection
• People with several first-degree relatives who have had
stomach cancer are more likely to develop this disease
• Epstein-Barr virus has also been found in the stomach
cancers of about 5% to 10% of people with this disease.
• These people tend to have a slower growing, less
aggressive cancer with a lower tendency to spread.
Reference: Harrison’s Principles of Internal Medicine, 17th ed.
www.cancer.org
 Complete
surgical removal of the tumor with
resection of adjacent lymph nodes
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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

Prognosis depends on the degree of tumor penetration into
the stomach wall.
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Probability of survival after 5 years
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Adversely influenced by regional lymph node involvement,
vascular invasion, and abnormal DNA content
~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:
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Resection of the primary lesion should still be offered.
Reduction of tumor bulk – best form of palliation; enhance
probability of benefit from subsequent therapy
 Major
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role: palliation of pain
Gastric adenocarcinoma is a relatively
radioresistant tumor.
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 5FU was given in combination with radiation
therapy.

5-FU: radiosensitizer

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.

Perioperative treatment and postoperative
chemotherapy + radiation therapy reduce the
recurrence rate and prolongs survival.
Thank You!