Gastric Carcinoma

Gastric Carcinoma Background Gastric carcinoma is the most common cancer in the world after lung cancer and is a major cause of mortality and morbidity.

Gastric Carcinoma • Background Adenocarcinomas account for approximately 95% of all malignant gastric neoplasms. The remaining 5% of tumors are : Lymphomas leiomyosarcomas carcinoids or sarcomas

Gastric Carcinoma

• Background • Though a marked reduction has been observed in the incidence of gastric carcinoma in North America and Western Europe in the last 50 years, 5-year survival rates are less than 20%, as most patients present late and are unsuitable for curative, radical surgery.

Gastric Carcinoma • Pathophysiology • The accepted pathway involves transitions from: • ► gastritis ►to gastric atrophy ► to metaplasia • ► to dysplasia ► •

and finally ► to cancer.

Gastric Carcinoma

• Pathophysiology • ► Several dietary and environmental factors may influence this pathway.

• ►Dietary nitrates • ►Hypochlorhydria • ►Helicobacter pylori

Gastric Carcinoma • Pathophysiology • ► Several dietary and environmental factors may influence this pathway.

• ►Certain foods e.g. (Starch, pickled vegetables, salted fish and meat, smoked foods, and salt have all been implicated in the development of gastric carcinoma).

Gastric Carcinoma

• Cigarette smoking: • Those who smoke more than 30 cigarettes per day have a 5-fold increased risk of gastric carcinoma.

Gastric Carcinoma • Several precancerous conditions are recognized

►Chronic atrophic gastritis

Gastric Carcinoma • Several precancerous conditions are recognized •

► Pernicious anemia

• • • • •

► Previous partial gastrectomy ► Ménétrier disease ► Gastric dysplasia ► Adenomatous polyps (20% of all gastric polyps) ► Hereditary factors

Gastric Carcinoma • ►Gastric adenocarcinomas are divided into 2 types:

• 1) An intestinal type (type 1), with well-formed glandular structures: • This type is more likely to involve the distal stomach and occur in patients with atrophic gastritis. It has a strong environmental association.

Gastric Carcinoma • ►Gastric adenocarcinomas are divided into 2 types • 2) A diffuse type (type 2), with poorly cohesive cells that tend to infiltrate the gastric wall: • Tumors of this type may involve any part of the stomach, especially the cardia, and have a worse prognosis than the intestinal type. • Unlike type 1 gastric cancers, type 2 cancers have similar frequencies in all geographic areas.

Gastric Carcinoma

• ► With gastric carcinomas, advanced lesions will have already invaded the muscularis propria.

• They are associated with metastases to regional lymph nodes or to local or distant structures.

Gastric Carcinoma

• ►Early gastric lesions are confined to the mucosa or submucosa. • Patients with these tumors have a 5-year survival rate of 90%. • Most reports are from Japan as a result of mass screening in that country.

Gastric Carcinoma • Before 1950, most gastric tumors detected were located in the antrum. • Since then, the location has gradually shifted from the antrum to the body and fundus because of the rapidly increasing incidence of carcinoma in the gastric cardia and lower esophagus.

• Today, 30% of gastric lesions are found in the antrum, 30% are in the body, and 40% are in the fundus and cardia.

• Illustration

Gastric Carcinoma • Frequency • Incidence • ► Low incidence: North America, Western Europe, Australia, and New Zealand • ► High incidence: Japan, Russia, China, South America, and Eastern Europe. • ► In India (highest rate in Mumbai, lowest Maharashtra state) • ► by Dr; MD.; Radhika Bobba

Gastric Carcinoma • Frequency • Incidence • ► In India • Highest rate in Mumbai. • Lowest Maharashtra state. ► by Dr. MD.; Radhika Bobba

Gastric Carcinoma • Mortality/Morbidity Most patients present late, and the 5-year survival rate is approximately 20%.

• Sex • Gastric carcinoma is 2 times more common in men than in women.

Gastric Carcinoma • Age • Gastric carcinoma has a peak incidence in those aged 50-70 years. • however, approximately 5% of patients with gastric cancer are younger than 35 years, and 1% are younger than 30 years.

• Younger patients have more aggressive lesions with a worse prognosis.

Gastric Carcinoma • Anatomy Recall • (They need not)

Gastric Carcinoma • Clinical Details • History • Most patients present with advanced disease because they are often asymptomatic in the earlier stages.

Gastric Carcinoma • Clinical Details • History • Common presenting features include: epigastric pain bloating early satiety nausea vomiting dysphagia anorexia weight loss (weakness, fatigue) and upper GI bleeding: Hematemesis, melena iron deficiency anemia positive results with fecal occult blood tests.

Gastric Carcinoma • Clinical Details • Physical examination • Looking for signs of disease such as: Skin and eyes (jaundice) Lumps Changes in the abdomen (fluid or swelling) Swollen lymph node ► ♂ Pelvic and Rectal examination

Gastric Carcinoma • Differential diagnosis • Because peptic ulcers and gastritis cause similar findings, diagnosis is often delayed. • Jaundice and hepatomegaly may be due to hepatic metastases. • Pelvic masses may be the result of ovarian metastases (Krukemberg’s tumors).

Gastric Carcinoma • • • • • •

Differential diagnosis Other Problems to be Considered Gastric lymphoma Gastric metastases Gastric varices Gastric polyps

Gastric Carcinoma

• Prognosis and staging • The prognosis is related to the stage of the disease at the time of diagnosis and to the histologic grade of the carcinoma.

Stage – 1

TNM Stage

5-Year Survival

T1N0M0, T1N1M0, or T2N0M0

88%

2

T1N2M0, T2N1M0, 65% or T3N0M0

3a

T2N2M0, T3N1M0, or T4N0M0

35%

3b

T3N2M0

35%

4

T4N1-3M0,

5%

Gastric Carcinoma • Lab examination • Perform blood tests including • full blood count determination • Liver, and kidneys function tests. • Inspect the stool, and test for occult blood.

Gastric Carcinoma • Imaging evaluation • Endoscopy. • Biopsy samples obtained during endoscopy. • Fiberoptic endoscopy or a double-contrast study of the upper GI tract. • CT scan • MRI • Ultrasonography (US)

Gastric Carcinoma • Treatment • • • • • • •

Neoadjuvant therapy Curative surgery Adjuvant therapy Palliative surgery Chemotherapy Radiation therapy Biological therapy (natural substances)