Download Adenocarcinoma: Linitis Plastica The rate of gastric

Adenocarcinoma: Linitis Plastica
The rate of gastric adenocarcinoma has decreased drastically in the United States,
but makes up 90-95% of all gastric cancer cases. Globally, a decrease has also
occurred and is attributed to environmental and socioeconomic changes. Despite
the drop, over 798,000 new cases of gastric cancer are diagnosed worldwide each
year. Prognosis for patients is based on tumor extent, nodule involvement,
extension of the tumor beyond the gastric walls, and sometimes the grade of the
tumor (1). The depth of invasion, or extension into muscularis propria is used to
distinguish between early and advanced stages. Overall, the 5 and 10 year survival
rates for advanced carcinoma are 46% and 35%, respectively. Survival rate is higher
when the tumor infiltrates only the distal two-thirds of the stomach. Tumor size is
directly correlated with survival rate in advanced carcinoma. Despite radical
treatment procedures, predictors of poor prognosis are >70 years old, tumor stage,
and need for total gastrectomy (2).
Linitis Plastica (3)
Pa tholog y a nd Na tura l History of Ga stric Ca nc er
287
Gastric Linitis Plastica (GLP), also known as Brinton’s
Disease or leather bottle stomach, involves diffuse
infiltration of the stomach lining. This causes
thickening and stiffening of gastric walls from the
Figure 23–8 Linitis plastica form of gastric cancer. Note the classical
leather bottle–like appearance. The wall is diffusely thickened.
Figure 23–10 Diffuse carcinoma. The individual tumor cells are widely
spaced andin
supported
by a dense desmoplastic
fundus to the pylorus and occurs
3-19%
of allstroma.
gastric cancer cases. Linitis Plastica
Common tumor typ es
Tubular adenocarcinomas contain prominent dilated or slit-like
and branching neoplastic tubules varying in diameter; acinar
structures may be present (Fig. 23–11). Individual tumor cells
may be columnar or cuboidal, or they become flattened by intraluminal mucin. The cells superficially resemble those found
in colonic adenocarcinomas. Clear cells also may be present. The
degree of cytological atypia varies from low to high grade.25,26
Poorly differentiated variants are sometimes called solid carcinomas. Tumors with a prominent lymphoid stroma sometimes
are called medullary carcinomas or gastric carcinomas with lymphoid stroma (Fig. 23–12).27 The degree of desmoplasia varies
and may be conspicuous in these neoplasms.
Papillary adenocarcinomas are well-differentiated exophytic
carcinomas with elongated finger-like processes lined by cylindrical or cuboidal cells supported by fibrovascular connective tissue cores. Goblet cells may be present. The cells tend to maintain their polarity. Some tumors show tubular differentiation.
Rarely, a micropapillary architecture is present. The degree of
cellular atypia and the mitotic index vary, and severe nuclear
from surrounding
structures. often
The tumor may
inhas a 1:1.3 female dominancedemarcated
and occurs
more
inbeyoung
individuals. These
atypia may be present. Usually the invading tumor edge is sharply
filtrated by acute and chronic inflammatory cells.
Mucinous adenocarcinomas are tumors composed of more
than 50% extracellular mucinous pools. The two major growth
patterns are (1) glands lined by a columnar mucus-secreting epithelium together with interstitial mucin (well-differentiated type)
and (2) chains or irregular cell clusters floating freely in mucinous lakes (Fig. 23–13). The latter pattern results from glandular rupture. Mucin also may be present in the interglandular
stroma. Scattered signet ring cells, when present, do not dominate the histological picture.
Signet ring cell carcinomas are adenocarcinomas in which
more than 50% of the tumor consists of isolated or small groups
of malignant cells containing intracytoplasmic mucin (Fig.
23–14). Superficially, cells lie scattered in the lamina propria,
often widening the distances between the pits and glands. The
tumor cells can also be quite subtle and can be easily missed
when they are few in number. The tumor cells have five morphologies: (1) nuclei that push against cell membranes, creating
a classical signet ring cell appearance because of an expanded,
globoid, optically clear cytoplasm; these contain acid mucin and
stain with Alcian blue at pH 2.5; (2) bland-appearing cells with
central nuclei that are easily mistaken for histiocytes because they
show little or no mitotic activity; (3) small, deeply eosinophilic
patients show a significantly lower survival rate. A study based on surgical
intervention of 102 individuals resulted in a median survival time of 5.7 months.
Diagnosis of GLP regularly occurs late and the tumor is often non-resectable. It is
staged using a esophagogastroduodenoscopy (EGD) with biopsy barium swallow
and thoracoabdominal CT (3).
The disease is believed to be correlated with heredity, poor diet, lack of exercise, or
H. pylori infection. Preserved, processed or smoked foods and poor quality water
contain nitrites, which form the potentially carcinogenic compound N-nitroso.
Nitrite, found in these foods, is a precursor to N-nitroso compounds. Nitrite reacts
with amines, amides and other protein to form N-nitroso compounds (4,5). Nitrate
does not react the same way, but can be reduced to nitrite by bacterial spoilage and
the bacteria in the mouth and upper GI tract (6). Studies found that patients with a
higher caloric, saturated fat, and oleic acid intake also had a higher incidence of
gastric adenocarcinoma.
It has been hypothesized that fruits and vegetables have a protective effect against
gastric carcinoma. The most significant effects seen have come from non-citrus and
raw fruit. Fruits and vegetables with nitrite scavenging properties of varying
mechanisms may be protective against stomach cancer. Vitamin C and E, Selenium,
and B-carotene/carotenoids are all potent antioxidants that scavenge free-radicals.
Vitamins C and E also inhibit intragastric formation of N-nitroso compounds (5,7).
Presentation and Complications:
Patients initially present with early satiety, postprandial abdominal pain, and
weight loss. These, along with other factors such as anorexia, intestinal obstruction,
taste changes, chemotherapy and radiation side effects, and depression can
contribute to malnutrition (8, 9). Patients with gastric cancer usually require a
partial or total gastrectomy with esophagojejunal anastomosis. Malnutrition prior to
surgery can lead to altered cellular immunity, increasing the risk of infection and
delaying wound healing. Patients with significant weight loss, or reduced caloric
intake for 2-24 weeks pre or post surgery are at risk for macro- and micronutrient
deficiencies. Post operatively, signs of significant weight loss, gastric stasis,
dumping syndrome, fat maldigestion, and iron, calcium, and B12 deficiency all need
to be monitored (4,10).
Dumping syndrome is one of many complications of extensive stomach resection.
Other complications can include fat malabsorption, gastric stasis, lactose
intolerance, anemia’s, and metabolic bone disease (11). Dumping syndrome occurs
in 25-50% of patients and begins when large amounts of food or liquid, especially
those high in simple carbohydrates, rapidly enter the small intestine (10). The
body’s response to dilute the high osmotic bolus results in gastrointestinal and
vasomotor symptoms such as abdominal cramps, diarrhea, nausea, vomiting,
flushing, faintness, diaphoresis, and tachycardia. (11). Dumping syndrome can be
classified as either early or late dumping. Early dumping happens within 10-30
minutes after meal consumption. Patients will often experience a feeling of fullness
and nausea attributed to small bowel distention plus a fluid shift into the small
intestine. Gastrointestinal and vasomotor symptoms are experienced: hypotension,
flushing, rapid heartbeat, faintness, vomiting, diarrhea, and headache. Late dumping
syndrome occurs 1-3 hours after a meal and is related to hypoglycemia. The rapid
delivery, hydrolysis, and absorption of CHO cause insulin to rise with a subsequent
decline in blood glucose. Patients experience vasomotor symptoms and may
perspire, feel anxious, weak, shaky, or hungry, and have difficulty concentrating.
Patients who experience dumping syndrome often loose weight due to fear and
anxiety associated with the symptoms (10, 11).
Malabsorption and steatorrhea occur secondary to rapid transit, loss of gastric,
lipase, or pancreatic/biliary insufficiency. Anemia, osteoporosis, and vitamin and
mineral deficiencies occur as the result of this malabsorption or due to limited
intake. Loss of gastric acid secretions and intrinsic factor may cause iron
complications. Gastric acid cleaves B12 from protein while intrinsic factor forms the
necessary complex with B12 for absorption in the ileum. Sometimes, the duodenum
and jejunum begin producing intrinsic factor, but if it is not produced in sufficient
quantities, pernicious anemia will result. Bacterial overgrowth in the small intestine
also causes a reduction in B12 absorption due to the bacteria completing for its use.
Many patients need prophylactic B12 injections (10, 11). Other common deficiencies
include calcium, folate (use RBC folate to diagnose) and fat soluble vitamins.
Patient Information:
SM is a 35 year old female of El Salvadorian decent who works at Costco. She is a
single mother to one child and estimated to be of moderate socioeconomic status
based on reported residence. She initially presented with complaints of early satiety
and mild emesis since February 2011. SM has no past medical history and is taking
no medications upon initial visit to physician. She does not smoke or drink, but does
have a history of poor eating habits. She has a family history of colon and prostate
cancer, leukemia, liver disease, and heart disease.
SM underwent an EUS where it was determined she has stage IIB gastric cancer.
She had three cycles of chemotherapy involving the antineoplastic drugs epirubicin,
oxaliplatnum, and zolotin (EOX). SM tolerated the Chemotherapy well with good
oral intake, no weight loss, and no GI complaints. After three rounds of
chemotherapy, a CT of the abdomen and pelvis was done, showing no significant
change in the poorly differentiated tumor’s size, but also no metastatic disease. SM
was scheduled for a laparotomy, gastrectomy, and Roux-En-Y reconstruction on May
25, 2012. She was admitted to Georgetown Hospital on the day of surgery, and then
transferred to inpatient recovery. The procedure resulted in total gastrectomy and
R1 resection with the creation of an esophagojejunal anastomosis, plus an additional
diagnosis of Linitis Plastica and metastasis to 2 lymph nodes.
Post operation day (POD) #6 the patient complained of shaking, chills, palpations,
and lightheadedness. Blood glucose was 77. It was determined that patient was
experiencing symptoms of late dumping syndrome and diet education was
reinforced with patient. Slightly over 3 hours later SM complained of tremoring on
her left side which lasted for approximately 2-5 minutes. She complained of left
sided tingling and numbness. It was determined she has an acute hemorrhage in
her right parietal lobe from transverse venous sinus thrombosis. She underwent
both a CT and MRI of the brain. She was transferred to Neurologic Intensive Care
Unit (NSICU) where she remains stable but has left sided sensory loss, photophobia,
and headaches with pain so great they result in nausea and vomiting. She had been
on heparin since POD #0, Coumadin was started POD #8 but D/C’d shortly after. She
has also been receiving daily CT scans since POD #8 to monitor spread of bleed and
midline shift.
Nutrition:
SM was NPO the day of her surgery, 5/25/12. She was given D5½NS with KCL at
100mL/hr. The following day she was allowed gum and hard candy. She continued
on the D5½NS. On POD #4 she under went an oral glucose intolerance test and
radiographic evaluation with the use of gastrographin. She was advanced to sips of
liquid, not including concentrated sweets and carbonated beverages. POD #5 SM’s
diet was advanced to clear liquid, again no concentrated sweets or carbonated
beverages. The following morning, the diet was progressed to full liquid and then to
a post gastrectomy diet by dinner. Post gastrectomy diet education was given on
5/31/12 to the patient and her sister. The educational session lasted about 30
minutes and was voice recorded by the family to refer to once outside of the
hospital. Main take home points for a post gastrectomy diet include: Eat small,
frequent meals, chew foods thoroughly and eat slowly, limit fluid consumption with
meals, limit high sugar foods and beverages, eat protein at each meal, and increase
fiber intake. Patient and sister were engaged in conversation and verbalized
understanding. Discharged was anticipated the following day. After the diet
education, the dietitian planned to follow up PRN. Pt was moved to the NSICU
6/1/12, she was trigged for RD referral on 6/6/12 for poor oral intake.
After speaking with the patient on 6/6/12, it was determined that she had a poor
appetite the past few days, but was feeling hungry most of the day. She had only
received a piece of bread for the previous nights dinner, and bread with bacon and
grapes for breakfast that morning. SM states that had she been given more than a
piece of bread she would have eaten more, the post gastrectomy diet was clarified
with catering services. SM remembered a lot of information from her previous diet
education, but mentions a fear of eating due to previous complication of dumping
syndrome. Patient was briefly re-educated on the post gastrectomy diet and how
dumping syndrome occurs. All her questions were clarified, and she appeared more
confident in the ability to manage her diet.
Nutrition Assessment
While completing diet education, SM admitted to previous poor eating habits but
since her diagnosis has changed her lifestyle. SM mentioned eating excessive
amounts of fried food, a lot of jerky, and consumed large quantities of soda. It is
unknown how much jerky SM ate but the curing process could result in an abnormal
amount of N-Nitroso compounds. Prior to diagnosis SM was a healthy weight
around 50kg. Her weight dropped drastically after her diagnosis, but she regained it
during her chemotherapy and radiation treatment. She is currently back to her
usual body weight of 52kg. She is 152cm tall, has a BMI of 22, and is at 111% of her
45kg IBW.
Shortly after surgery SM’s potassium (3.4mEq/L) and phosphorus (2.0mg/dL) were
low, but repleated. Bun and creatinine were consistently low with BUN ranging
from 3-6mg/dL and creatinine ranging from 0.26-0.44mg/dL. This could be the
result of inadequate protein intake. Sodium ranged from 133-136mEq/L. Over the
course of her stay, SM was taking the following medications which have nutritional
implications: D5½NS, potassium chloride, magnesium sulfate, sodium chloride,
ferrous sulfate, docusate-senna, warfarin, and vitamin C.
SM was determined to need 30-35 kcal/kg and 1.5-1.7g protein/kg. She was
advanced to a post gastrectomy diet as tolerated, provided with Glucerna three
times a day (TID) and given a daily multivitamin. Her oral intake intake is
monitored, and though low there is no need for nutrition support at this time. The
following goals were set: Eat >75% of meals and supplements and prevent weight
loss.
She has been gradually increasing the amount of food consumed while in the NSICU.
Unless there is a significant change in her ability to eat, she will continue on a post
gastrectomy diet for life. It will be up to her to determine what foods her body can
tolerate, and what foods warrant unwanted side effects. Foods that cause adverse
effects should be slowly reintroduced into the diet one at a time. Ideally, she will
return to consuming a balanced diet of a large variety within six weeks. Based on
research her prognosis is poor, but with her young age, and large support system, it
is hopefully that her cancer will remain localized and/or has been completely
removed, and will not metastasize. SM was discharged on 6/19/12.
Study: Limited Efficacy of Early Enteral Nutrition in Patients after Total
Gastrectomy (12).
Introduction: Nutritional status has a large impact on surgery outcome. Patients
who undergo GI surgery often suffer from malnutrition leading to increased
postoperative morbidity and prolonged hospital stay. Artificial intake has been
suggested when oral intake will be absent 5-7 days after surgery. Enteral Nutrition
(EN) is the preferred method as it has decreased risk of infection than Total
Parenteral Nutrition (TPN). The biological and clinical benefits of early EN to
patients undergoing gastric surgery due to gastric cancer are currently unknown.
This study compares early EN via NJ tube to patients receiving TPN after total
gastrectomy.
Materials/Methods: Retrospective study of patients with total gastrectomy and
Roux-en-Y esophagojejunostom. Total enrolled -116; EN – 62; TPN – 54. Feeding
was started within 24 hours with a goal of 20-25kcal/day and was supplemented
until at least 1000kcal/day was tolerated. Oral intake was administered on day 6-7
as patient desired. Gradually reduced supplemental nutrition with increased oral
intake. TPN contained 50-60% glucose and 40-50% fat. Patient was discharged
under the following criteria (1) no fever for 2+ days or signs of inflammation; (2)
able to eat more than ½ a solid diet; and (3) able to treat own wounds without any
assistance.
Results: 116 total patients between 38 and 82 years old. Baseline characteristics
(age, gender, BMI, nutritional status, comorbidity, tumor site, operating time, etc)
were similar. Post op length of stay, time of flatus passage, and time before starting
semi-solid diet were the same in both group. Patients in TPN group started a liquid
diet sooner. EN group developed diarrhea and abdominal distention more often, but
not of statistical significance. Symptoms from EN could be alleviated by lowering the
infusion rate. No significant difference between post op mortality in the two groups.
Discussion: About 60% of gastric cancer cases have some form of malnutrition. TPN
increased the overall risk of complications by 10% and showed higher rates of
hyperglycemia complications. There is no significant difference in major and minor
complications postoperatively in EN or TPN groups. Since EN showed no beneficial
effects on decreasing risk of complications, the study says EN is not warranted over
TPN in patients after total gastrectomy due to possible respiratory infections (no
difference in lung infection or pneumonia was reported between the two groups). I
would not agree with this outcome – if no difference is reported, EN helps in
maintaining normal gut function, reduces risk of infection, and is much less
expensive compared to TPN.
Works Cited
1. Abbruzzese, JL. Gastrointestinal Oncology. Oxford University Press. 2004; 257264.
2. Nakamura K, Ueyama T, Yao T, Xuan ZX, Ambe K, Adachi Y, Yakeishi Y,
Matsukuma A, Enjoji M. Pathology and Prognosis of Gastric Carcinoma.
Cancer. 1992; 70(5):1030-1037.
3. Pedrazzini C, Marrelli D, Pacelli F, DiCosmo M, Mura G, Bettarini F, Rosa F,
deManzoli G, Roviello F. Gastric Linitis Plastica: Which Role for Surgical
Resection?. Gastric Cancer. 2012; 15:56-60.
4. Swann PF. Carcinogenic Risk from Nitrite, Nitrate and N-Nitrosamines in Food.
Proceedings of the Royal Society of Medicine. 1977; 70(2):113-115.
5. Kono S, Hirohata T. Nutrition and Stomach Cancer. Cancer Causes Control. 1996;
7(1):41-55.
6. Sandor J, Kiss I, Farkas O, Ember I. Gastric Cancer Mortality and Nitrate Content of
Drinking Water: Ecological Study on Small Area Inequalities. Europeal Journal
of Epidemiology. 2001; 17(5):443-447.
7. Harrison LE, Zhang ZF, Karpeh MS, Sun M, Kurts RC.The Role of Dietary Factors in
the Intestinal and Diffuse Histologic Subtypes of Gastric Adenocarcinoma: A
Case-Controlled Study in the U.S. Cancer. 1997; 80(6):1021-8.
8. Scolapio JS, Buchman AL. Clinician’s Guide to Gastrointestinal Oncology. SLACK
Inc. 2005; 307-216.
9. Radigan A. Post-Gastrectomy: Managining the Nutrition Fall-Out. Practical
Gastroenterology. 2004; 18:63-75.
10. Rogers, C. Postgastrectomy Nutrition. Nutrition in Clinical Practice. 2011;
26(2):126-136.
11. Mahan LK, Escott-Stump S. Krause’s Food & Nutrition Therapy. 12th ed. St. Louis,
MI: Saunders Elsevier: 2008: 977, 667-668.
12. Li J, Ji Z, Yuan C, Zhang Y, Chen W, Ju X, Tang W. Limited Efficacy of Early Enteral
Nutrition in Patients after Total Gastrectomy. Journal of Investigative
Surgery. 2011;24:103-108.