Benign Tumors Of The Stomach

BENIGN TUMORS OF THE STOMACH BACKGROUND Approximately 7% of premortem gastric tumor are benign.

A recent series of 5554 patients undergoing upper gastrointestinal endoscopy suggested an incidence of 0.8% of the total population screened.

BENIGN TUMORS OF THE STOMACH • BACKGROUND

►The mean age of the patient was 56 years, with a fivefold greater incidence in females. ►Benign tumor constitute less than 2% of true gastric neoplasms found at the time of autopsy. ►Approximately 3% of those discovered at the time of endoscopy in symptomatic patients.

BENIGN TUMORS OF THE STOMACH • BACKGROUND • Approximately 40% of these tumor are ►mucosal epithelial polyps, another 40% are ►leiomyomas. • And all the remaining types are rare.

BENIGN TUMORS OF THE STOMACH

• Polyps • Polyp is generally used to describe any growth that protrudes into the gastric lumen. • Almost all gastric polyps arise from the mucosal epithelium.

BENIGN TUMORS OF THE STOMACH

• Polyps • The nomenclature of gastric polyps is confusing largely because of early attempts to present them as being analogous to colorectal polyps in microscopic appearance and natural history.

BENIGN TUMORS OF THE STOMACH • Polyps • Polyps vary between 1 cm and 2 cm. in diameter and have no predicable location within the stomach. • Multiple polyps in the same patient are almost always of the same histologic type.

BENIGN TUMORS OF THE STOMACH • Polyps • Hyperplastic polyps

• ►Also know as regenerative, inflammatory, hyperplaslogenic, or hamartomatous polyps. • (constitute 75% of all gastric epithelial polyps)

► They may vary in size from few millimeters to several centimeters.

BENIGN TUMORS OF THE STOMACH • Polyps • Hyperplastic polyps • Most are less than 2cm. • The gastric lesion termed polyadenomes polypeux corresponds to multiple heperplastic polyps. • And cystic component referred to as gastristis polyposis cystica.

BENIGN TUMORS OF THE STOMACH

• Polyps • Neoplastic polyps or adenomas • These polyps are usually antral in location, are usually single and large. (and may be sessile or pedonculated). • They can be divided into adenomatous polyps (tubular adenoma) and villous adenoma.

BENIGN TUMORS OF THE STOMACH • Polyps • Fundic gland polyps • They are fundic gland hyperplasia • polyps with fundic glandular cystic.

• Present as multiple small polypoid projections in the gastric fundus or body. ( They are common in FAP patients)

BENIGN TUMORS OF THE STOMACH

• Polyps • Inflammatory fibroid polyps Also known as eosinophilic granuloma, granulomablastoma, neurofibroma, and hemangiopericytoma.

BENIGN TUMORS OF THE STOMACH

• Gastric polyps in polyposis syndromes • Gastric involvement occurs in over 50% of patients with familial polyposis coli (FAP) and related Gardner’ syndrome.

BENIGN TUMORS OF THE STOMACH

• Intramural Tumors • Leiomyomas • Are the most common benign tumor of the stomach reported at autopsy. • There is a spectrum from benign to malignant.

• The only reliable indicator of malignancy in these and other GISTs is evidence of extragastric spread

BENIGN TUMORS OF THE STOMACH • Intramural Tumors • Leiomyomas • These tumors can cause symptoms by obstruction, ulceration, and blood loss or by compressing adjacent organs.

BENIGN TUMORS OF THE STOMACH Heterotopic pancreas • An aberrant rest of pancreas tissue located in the wall of the stomach. • Presents clinically as a tumor and must be considered in the differential diagnosis of benign gastric neoplasms.

BENIGN TUMORS OF THE STOMACH

• Brunner’s Gland Adenoma. • Brunner’s gland adenoma can occur in the antrum or juxtapyloric region, representing heterotopic locations of a hamartomatous lesion that is usually found in the duodenum.

BENIGN TUMORS OF THE STOMACH

• Hyperplastic Gastropathy • The general term hyperplastic gastropathy refers to a rare condition in which there is enlargement of the rugal folds in the stomach. ► Polyadenome en nappe (Menetrier disease) ► Multiple hyperplastic polyps

BENIGN TUMORS OF THE STOMACH • Hyperplastic Gastropathy • Menetrier’s Disease • Is characterized by gastric mucosal hypertrophy that may be so extensive that the rugae assume the appearance of convolutions of the brain.

BENIGN TUMORS OF THE STOMACH

• Hyperplastic Gastropathy • Pseudolymphoma • This is extensive lymphocytic infiltration of a portion of the stomach, Generally associated with a benign gastric ulcer.

BENIGN TUMORS OF THE STOMACH • Cystic tumors • Cystic tumors can be mucocele or intramucosal, and they are the most common benign cystic lesion of the stomach.

BENIGN TUMORS OF THE STOMACH • Clinical Presentation • History • Benign gastric tumors occurs predominantly in the middle decades of life. • And are most commonly located in the gastric antrum or corpus.

• Tumor of the cardia and pylorus proper are rare.

BENIGN TUMORS OF THE STOMACH • Clinical Presentation • History • Complaints may be:

• • • • •

Pain Indigestion Obstruction (vomiting) Weight loss or unexplained anemia (occult blood loss??)

BENIGN TUMORS OF THE STOMACH

• Clinical Presentation • History • Because of the propensity of these tumors to ulcerate the associated mucosal epithelium, the resultant occult blood loss can cause iron-deficiency ►►anemia.

BENIGN TUMORS OF THE STOMACH • Clinical Presentation • History • ►Deep ulcerations that overlie intramural tumors are notorious for their association with overt hemorrhage. ► Bleeding ► hematemesis, melena

• ►Ulceration may cause syndrome indistinguishable from that caused by peptic ulcer disease.

BENIGN TUMORS OF THE STOMACH

• Clinical Presentation • History • Patients may therefore have an ill-defined sense of epigastric discomfort and an associated sense of fullness ►that is often caused by large size of the tumor or episodic obstruction of digestive tract. (if pedonculated)

BENIGN TUMORS OF THE STOMACH • Clinical Presentation • History This obstruction may be partial early, which progresses to complete obstruction as the tumor grows larger. ►► Vomiting

BENIGN TUMORS OF THE STOMACH

• Clinical Presentation • History • Frank gastroduodenal intussusception secondary to prolapsing gastric tumors may occur. ►► obstruction

BENIGN TUMORS OF THE STOMACH • Clinical Presentation • History • The tumor may become huge exogastric tumors and detected by the patient as a palpable mass.

BENIGN TUMORS OF THE STOMACH • Physical Examination • Physical findings are not specific except for underlying conditions such as Peutz-Jeghers syndrome. •

An abdominal mass may be palpable.

• Palpation may elicit abdominal tenderness.

BENIGN TUMORS OF THE STOMACH Diagnosis ► Incidental discovery at the time of laparotomy. ► During the course of barium meal study. ► Or during gastroscopy for a probably unrelated disease is the most common method of detection.

BENIGN TUMORS OF THE STOMACH

• Lab Studies

• ►♂ • • • •

Findings on laboratory serum tests are nonspecific.

Routine blood test (Anemia ?) Routine stool test ? Liver, spleen function tests ? CAE (leiomyoma)?

Imaging studies Biopsy material ?? Endogastric Intramural Sonography For examination of the gastric wall CT scan? ECG?

BENIGN TUMORS OF THE STOMACH

• Treatment • Surgery • Endoscopy • Celiotomy

• NEXT

Lymphoma of the stomach

• Background • The second most common primary cancer of the stomach but constitute only 2-5% of the total number, 95% being adenocarcinomas. (almost all are

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non-Hodgkin's lymphoma, and generally classified as B cell mucosaassociated lymphoid tissue (MALT)) lymphoma. About 20% of patients manifest a second primary cancer in another organ. Also classified as low grad or high-grade base on nuclear pattern.) Macroscopically: infiltrative, ulcerative, nodular, polypoid, and combines

Explications •

MALT lymphoma is a type of NHL that starts outside the lymphatic system. MALT stands for mucosa-associated lymphoid tissue. It means that the lymphoma begins to grow in lymphatic tissue that is found in the lining of other organs

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MALT lymphoma is commonest in the stomach. It is linked to a bacterial infection called helicobacter pylori. Research over the past few years has discovered that treating the infection with antibiotics can put MALT lymphoma of the stomach into remission. It is to early to say how long the remission lasts. Treating the infection may actually cure this rare type of NHL

Lymphoma of the stomach • Background • There are many different non-Hodgkin's lymphoma (NHL). ► Low-grade NHL ► High-grade NHL ► Cutaneous T cell lymphoma (rare, it is mycosis fungoides, lymphoma that affects the skin)

Lymphoma of the stomach

Low-grade NHL May be Large or small Grouped together (follicular type) Spread out (diffuse type)

Lymphoma of the stomach • • • • • • •

Low-grade NHL Small cell lymphocytic Follicular Mantle cell Splenic marginal zone lymphoma MALT lymphoma Lymphoplasmacytic NHL (also called Waldenstrom's macroglobulinaemia)

Lymphoma of the stomach • • • • • •

High grade NHL Diffuse large B cell Diffuse mixed cell lymphoma Burkitt lymphoma Anaplastic large cell lymphoma Diffuse mixed cell lymphoma

Lymphoma of the stomach • Transforming from low grade to high grade • Over time, low grade lymphomas may change into a more aggressive high grade type lymphoma. If it does, it may be several years after you were first diagnosed with the low grade lymphoma. ►► higher grade type ►poorer prognostic

Lymphoma of the stomach

• Clinical presentation • History • Strikingly similar to that of adenocarcinoma of the stomach making the diagnosis very difficult.

Lymphoma of the stomach • Clinical presentation • History • Patients with primary gastric lymphoma are usually in their mid-fifties, with a male-to-female predominance of 1.7 to 1.

• Less than 20% of patients present asymptomatically.

Lymphoma of the stomach • Clinical presentation • History • Pain: • The major symptom, occurring in over 80% of patients, and it may be associated with: anorexia • early satiety • nausea • and vomiting.

Lymphoma of the stomach

• Clinical presentation • History • • • •

Vague symptoms Such as Weakness Malaise are also relatively common.

Lymphoma of the stomach

• Clinical presentation • History • Remember • • • • •

In case of diffuse lymphoma ►► night sweats weight loss fever Can be present in up to 40%.

Lymphoma of the stomach

• Clinical presentation • History • Remember: • 42% of Patients presented with emergency complication of gastrointestinal lymphoma: • Bleeding • Perforation • Obstruction • Fistula

Lymphoma of the stomach • Clinical presentation • History • Gastric lymphoma may also occurs following: ► surgical treatment for peptic ulcer ► treatment of Hodgkin's disease ► Chrohn’s disease ► or following immunosupression for renal transplantation

Lymphoma of the stomach • Physical Examination • Patients with primary gastric lymphoma sometimes present with abdominal findings suggestive of a mass in the left upper quadrant.

• Most commonly there are no abdominal findings unless there is a complication of the tumor.

Lymphoma of the stomach • Physical Examination • Splenomegaly is occasionally found in patients with direct extension of the lymphoma to the spleen. • Massive splenomegaly may indicate diffuse lymphoma.

Lymphoma of the stomach

• Physical Examination • Other findings that suggest diffuse or abdominal lymphoma include: • palpable peripheral adenopathy • or large retroperitoneal mass.

Lymphoma of the stomach • • • • •

Diagnosis Upper Gastrointestinal Radiology Ultrasonography CT scan Gastrointestinal endoscopy

Lymphoma of the stomach

• Treatment • Medical (Helicobacter pylori) • • • •

► According to the stage Surgery Chemotherapy Radiation therapy