1. Prof. Faisal Ghani Siddiqui FCPS; PGDip-bioethics; MCPS-HPE
THE GASTRIC CARCINOMA
Prof. Faisal Ghani Siddiqui
FCPS; PGDip-bioethics; MCPS-HPE

2. Preamble Epidemiology Aetiologic factors Pathology Clinical features
Investigations
Treatment

3. Adenocarcinoma -Epidemiology
Incidence  in USA/western Europe
Leading cause of death in Asia/Eastern Europe
Elderly
Blacks
Low SE status

4. What causes Gastric Cancer?

5. Gastric Cancer Pernicious anaemia Blood group A
Family history of gastric cancer

6. Gastric Cancer Diet High fat diet Pickled, preserved food Tobacco
Fresh fruit and vegetables
Vitamin C
Regular aspirin

7. Gastric Cancer Genetic Mutations
Deletion or suppression of p53
Overexpression of COX-2
CDH1

8. Gastric Cancer Pre-malignant Conditions
Polyps
Atrophic gastritis
Benign gastric ulcer
Gastric ramnant

9. Superficial gastritis Intestinal metaplasia
H.Pylori infection
Superficial gastritis
Atrophic gastritis
Intestinal metaplasia
Dysplasia
Cancer

12. Gastric Cancer Pathology

13. Malignant Neoplasms of the Stomach
Primary
Adenocarcinoma (94%)
Lymphoma (4%)
Malignant GIST (1%)
Haematogenous spread
Breast
Malignant melanoma
Direct invasion
Pancreas; Liver; colon; ovary

14. Gastric Cancer Gross Appearance
Polypoid
Fungating
Ulcerative
Scirrhous

15. Gastric Cancer Histology –Lauren Classification
Intestinal
Diffuse
Unclassified

16. Gastric Cancer TNM staging
Tis
Intaepithelial tumour T1
Tumour invades LP or submucosa T2
Tumour invades muscularis propria or subserosa T3
Tumour penetrates serosa without invasion of adjacent structures T4
Tumour invades adjacent structures

17. Gastric Cancer TNM staging
No regional lymph node metastases N1
Metastasis in 1 to 6 regional lymph nodes N2
Metastasis in 7 to 15 regional lymph nodes N3
Metastasis in more than 15 regional lymph nodes

18. Gastric Cancer TNM staging
No distant metastasis M1
Distant metastasis

19. Gastric Cancer Clinical Manifestations

20. Symptoms Weight loss Decreased food intake Abdominal pain
Nausea, vomiting and bloating
Acute GI bleeding
Chronic GI bleeding
Dysphagia

21. Trousseau’s syndrome (thrombophlebitis)

22. Acanthosis Nigracans

23. Clinical Signs Cervical, supraclavicular and axillary lymphadenopathy
Pleural effusion
Aspiration pneumonitis
Abdominal mass
Sister Joseph’s nodule
Ascites
Rectal shelf of Blumer

25. Rudolph Virchow

26. Gastric Cancer Diagnostic Evaluation

27. 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

28. Preoperative Staging Abdominal / pelvic CT scanning
Endoscopic ultrasound (EUS)
Depth of the tumour
Enlarged perigastric/coeliac lymph nodes

30. Gastric Cancer Treatment

31. Surgical Resection & Adequate Lymphadenectomy is the only curative treatment except
Metastases
Co-morbid

32. 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

33. Radical subtotal gastrectomy
Extent of Gastrectomy
Radical subtotal gastrectomy
(Distal tumour)
Total gastrectomy
(Proximal tumour)

36. Lymphadenectomy

37. D1: stations 3-6
D2: stations 1,2, 7,8 and 11
D3: stations 9, 10 and 12

38. adjuvant radio-chemotherapy
Survival benefit to
adjuvant radio-chemotherapy
is marginal in patients who have undergone adequate resection

39. Role of palliative chemotherapy
In gross unresectable, metastatic tumour
Role of palliative chemotherapy
is uncertain