THE
GASTRIC
CARCINOMA
Prof. Faisal Ghani Siddiqui
FCPS; PGDip-bioethics; MCPS-HPE
Preamble
• Epidemiology
• Aetiologic factors
• Pathology
• Clinical features
• Investigations
• Treatment
Adenocarcinoma -Epidemiology
• Incidence  in USA/western Europe
• Leading cause of death in Asia/Eastern Europe
• Elderly
• Blacks
• Low SE status
What causes
Gastric Cancer?
Gastric Cancer
• Pernicious anaemia
• Blood group A
• Family history of gastric cancer
Gastric Cancer
Diet
•
•
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•
•
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High fat diet
Pickled, preserved food
Tobacco
Fresh fruit and vegetables
Vitamin C
Regular aspirin
Gastric Cancer
Genetic Mutations
• Deletion or suppression of p53
• Overexpression of COX-2
• CDH1
Gastric Cancer
Pre-malignant Conditions
• Polyps
• Atrophic gastritis
• Benign gastric ulcer
• Gastric ramnant
H.Pylori infection
Superficial gastritis
Atrophic gastritis
Intestinal metaplasia
Dysplasia
Cancer
Gastric Cancer
Pathology
Malignant Neoplasms of the
Stomach
Primary
Adenocarcinoma (94%)
Lymphoma (4%)
Malignant GIST (1%)
Haematogenous spread
Breast
Malignant melanoma
Direct invasion
Pancreas; Liver; colon; ovary
Gastric Cancer
Gross Appearance
Polypoid
Fungating
Ulcerative
Scirrhous
Gastric Cancer
Histology –Lauren Classification
Intestinal
Diffuse
Unclassified
Gastric Cancer
TNM staging
Tis
T1
T2
T3
T4
Intaepithelial tumour
Tumour invades LP or submucosa
Tumour invades muscularis propria or subserosa
Tumour penetrates serosa without invasion of
adjacent structures
Tumour invades adjacent structures
Gastric Cancer
TNM staging
N0
No regional lymph node metastases
N1
N2
Metastasis in 1 to 6 regional lymph nodes
Metastasis in 7 to 15 regional lymph nodes
N3
Metastasis in more than 15 regional lymph nodes
Gastric Cancer
TNM staging
M0
No distant metastasis
M1
Distant metastasis
Gastric Cancer
Clinical Manifestations
Symptoms
• Weight loss
• Decreased food intake
• Abdominal pain
• Nausea, vomiting and bloating
• Acute GI bleeding
• Chronic GI bleeding
• Dysphagia
Trousseau’s syndrome
(thrombophlebitis)
Acanthosis
Nigracans
Clinical Signs
• Cervical, supraclavicular and axillary
lymphadenopathy
• Pleural effusion
• Aspiration pneumonitis
• Abdominal mass
• Sister Joseph’s nodule
• Ascites
• Rectal shelf of Blumer
Rudolph Virchow
Gastric Cancer
Diagnostic Evaluation
Prompt
upper endoscopy if …
• New onset of dyspepsia >45 years
• Dyspepsia with alarm symptoms
(weight loss, anaemia, recurrent
vomiting, bleeding)
• Dyspepsia & family h/o gastric
carcinoma
Preoperative Staging
• Abdominal / pelvic CT scanning
• Endoscopic ultrasound (EUS)
– Depth of the tumour
– Enlarged perigastric/coeliac lymph nodes
Gastric Cancer
Treatment
Surgical Resection &
Adequate Lymphadenectomy
is the only curative treatment
except
• Metastases
• Co-morbid
Surgical Resection
• Resection of tumour
• Grossly negative margin of at least 5 cms
• Partial gastrectomy
• Confirmed on frozen section
• En block resection of adjacent involved
organs
Extent of Gastrectomy
• Radical subtotal gastrectomy
(Distal tumour)
• Total gastrectomy
(Proximal tumour)
Lymphadenectomy
• D1: stations 3-6
• D2: stations 1,2, 7,8 and 11
• D3: stations 9, 10 and 12
Survival benefit to
adjuvant radio-chemotherapy
is marginal in patients who have undergone
adequate resection
In gross unresectable, metastatic tumour
Role of palliative
chemotherapy
is uncertain