Presentation on theme: "GASTRIC CA Ruanto, M.T., Sabalvaro, D.K., Salac, C.N., Salazar, J."— Presentation transcript:
1GASTRIC CA Ruanto, M.T., Sabalvaro, D.K., Salac, C.N., Salazar, J. References: Harrison’s Principle of Internal Medicine 17th edition
2EPIDEMIOLOGY GASTRIC ADENOCARCINOMA Decrease incidence and mortality rates for gastric CA during past 75 years (unclear reasons)Risk: lower > higher socioeconomic classesDevelopment:Environmental exposure beginning early in lifeDietary carcinogens
3EPIDEMIOLOGY PRIMARY GASTRIC LYMPHOMA Uncommon: <15% of gastric malignancies~2% of all lymphomasStomach – most frequent extranodal site for lymphomaIncreased in frequency during the past 30 daysDetected during the 6th decade of life
5CLINICAL FEATURES ADENOCARCINOMA Asymptomatic - superficial & surgically curableinsidious upper abdominal discomfort (vague, postprandial fullness to severe steady pain) - extensive tumorsAnorexia with slight nauseaWeight loss, nausea & vomiting - tumors of the pylorusdysphagia & early satiety - diffuse lesions originating in cardiaNo early physical signsPalpable abdominal mass – long-standing growth, regional extension
6CLINICAL FEATURES ADENOCARCINOMA Metastases: Malignant ascites intraabdominal lymph nodessupraclavicular lymph nodesOvary (Krukenberg’s tumor)Periumbilical region (“Sister Mary Joseph node”)Peritoneal cul-de-sac (Blumer’s shelf): palpable on rectal or vaginal examinationMalignant ascitesLiver – most common site for hematogenous spread of tumorUnusual clinical features: migratory thromboplebitis, microangiopathic hemolytic anemia & acanthosis nigrans
7CLINICAL FEATURES PRIMARY GASTRIC LYMPHOMA Epigastric pain, early satiety & generalized fatigueUlcerations with ragged, thickened mucosal pattern by contrast radiographsGASTRIC (NONLYMPHOID) SARCOMAAnterior and posterior walls of gastric fundusmost frequently involvedUlcerate and bleedRarely invade adjacent visceraDo not metastasize to lymph nodesMay spread to liver and lungs
8DIAGNOSIS Double contrast radiographic examination Gastroscopy Simplest procedure – epigastric complaintsHelps detect small lesions by improving mucosal detailStomach should be distended decreased distensibility may be the only indication of diffused infiltrative carcimomaGastroscopyNot mandatory if:Radiographic features are typically benignComplete healing can be visualized by x-ray within 6 weeksFollow-up contrast radiograph obtained several months later shows a normal appearance
9DIAGNOSIS Gastroscopic biopsy and brush cytology Should be made as deeply as possibleRecommended in all patients with gastric ulcers to exclude malignancyMalignant ulcers must be recognized before they penetrate into surrounding tissuesRate of cure of early lesions limited to mucosa and submucosa is >80%
10Staging system for gastric ca StageTNMFeaturesNo. of Cases %5 year survival, %TisN0M0Node negative;Limited to mucosa190IAT1N0M0Invasion of lamina propria or submucosa759IBT2N0M0Invasion of muscularis propria1044IIT1N2M0T2N1M0Node positive; invasion beyond mucosa but within wall1729T3N0M0Node negative, extension through wallIIIAT2N2M0T3N1-2M0Node positive; invasion of muscularis propria or through wall2115IIIBT4N0-1M0Node negative; adherence to surrounding tissue149IVT4N2M0Node positive; adherence to surrounding tissue303T1-4N0-2M1Distant metastases
12Reference: Harrison’s Principles of Internal Medicine, 17th ed. H. Pylori infectiona 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 stomachGenderStomach cancer is more common in men than in women.AgingThere 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.
13Reference: Harrison’s Principles of Internal Medicine, 17th ed. EthnicityIt is most common in Asian/Pacific Islanders.DietAn 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.
14Reference: Harrison’s Principles of Internal Medicine, 17th ed. Tobacco useSmoking 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.ObesityBeing 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.
15Previous 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.Pernicious anemiaCertain cells in the stomach lining normally make intrinsic factor (IF), which is a substance needed to absorb vitamin B12 from foods.People without enough IF may end up with a vitamin B12 deficiency, which affects the body's ability to make new red blood cells.Menetrier diseasea 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.
16Inherited cancer syndromes 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 70% to 80%.Researchers recently discovered the gene (E-cadherin/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.People who carry mutations of the inherited breast cancer genes BRCA1 and BRCA2 may also have a higher rate of stomach cancer.Reference: Harrison’s Principles of Internal Medicine, 17th ed.
17Reference: Harrison’s Principles of Internal Medicine, 17th ed. Type A bloodFor unknown reasons, individuals with Type A blood have an increased risk of developing gastric cancer.Family history of gastric cancerPeople with several first-degree relatives who have had stomach cancer are more likely to develop this diseaseEpstein-Barr infectionEpstein-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.
19SURGICAL TREATMENTComplete surgical removal of the tumor with resection of adjacent lymph nodesOnly chance for curePossible in <1/3 of patientsSubtotal gastrectomy – distal carcinomasTotal or near-total gastrectomies – more proximal tumorsExtended lymph node dissection – an added risk for complications, do not enhance survival
20SURGICAL TREATMENTPrognosis depends on the degree of tumor penetration into the stomach wall.Adversely influenced by regional lymph node involvement, vascular invasion, and abnormal DNA contentProbability of survival after 5 years~20% for distal tumors<10% for proximal tumorsRecurrences continuing for at least 8 years after surgeryFor patients whose disease is “incurable” by surgery with no ascites or extensive hepatic or peritoneal metastasis:Resection of the primary lesion should still be offered.Reduction of tumor bulk – best form of palliation; enhance probability of benefit from subsequent therapy
21Radiation Therapy Major 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 5- FU was given in combination with radiation therapy.5-FU: radiosensitizer
22Pharmacologic Therapy Cisplatin + epirubicin & infusional 5-FU or + irinotecanComplete 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.