Carcinoma stomach
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Transcript of Carcinoma stomach
© 2004, 2002 Elsevier Inc. All rights reserved.
Carcinoma stomachCarcinoma stomach
© 2004, 2002 Elsevier Inc. All rights reserved.
EpidemiologyEpidemiology
2.5% of all cancer related death.
Overall incidence decreasing.
Incidence varies with geographic areas. Highest in Japan, Chile, Cosat rica. 20 fold higher than…..
SE Asia, North America, North Europe, Africa.
2.5% of all cancer related death.
Overall incidence decreasing.
Incidence varies with geographic areas. Highest in Japan, Chile, Cosat rica. 20 fold higher than…..
SE Asia, North America, North Europe, Africa.
© 2004, 2002 Elsevier Inc. All rights reserved.
Epidemiology Epidemiology
Mass endoscopy program is high yielding in case of high incidence areas, where 35% of newly detected cases are of Early Gastric Cancer.
Environment plays a important risk factor in causation of Gastric ca.
Mass endoscopy program is high yielding in case of high incidence areas, where 35% of newly detected cases are of Early Gastric Cancer.
Environment plays a important risk factor in causation of Gastric ca.
© 2004, 2002 Elsevier Inc. All rights reserved.
Early gastric carcinomaEarly gastric carcinoma
© 2004, 2002 Elsevier Inc. All rights reserved.
Risk factors…Risk factors…
H. pylori infection
Gender
Aging
Smoking
Ethnicity
Diet
Tobacco
Obesity
H. pylori infection
Gender
Aging
Smoking
Ethnicity
Diet
Tobacco
Obesity
Previous gastric surgery
Pernicious anaemia
Menetrier’s disease
Inherited cancer syndrome
Family history +
Type A blood group
EBV infection
Previous gastric surgery
Pernicious anaemia
Menetrier’s disease
Inherited cancer syndrome
Family history +
Type A blood group
EBV infection
© 2004, 2002 Elsevier Inc. All rights reserved.
Cancer of gastric Cardia…Cancer of gastric Cardia…
Is on rise…
Probably related to Barrett esophagus as also chronic GERD and obesity.
Clinical behavior similar to distal esophageal adenocarcinoma.
Is on rise…
Probably related to Barrett esophagus as also chronic GERD and obesity.
Clinical behavior similar to distal esophageal adenocarcinoma.
© 2004, 2002 Elsevier Inc. All rights reserved.
Is there anyone to protect…?Is there anyone to protect…?
Green leafy vegetables
Citrus food
Green leafy vegetables
Citrus food
© 2004, 2002 Elsevier Inc. All rights reserved.
Classification Classification
Gastric carcinoma (microscopically Laurenn’s classification)– Intestinal type
– Diffuse type
Gastric carcinoma (macroscopically Bormann’s classification)– Type I (polypoid)
– Type II (fungating)
– Type III (ulcerated)
– Type IV (infiltrative)
Gastric carcinoma (microscopically Laurenn’s classification)– Intestinal type
– Diffuse type
Gastric carcinoma (macroscopically Bormann’s classification)– Type I (polypoid)
– Type II (fungating)
– Type III (ulcerated)
– Type IV (infiltrative)
© 2004, 2002 Elsevier Inc. All rights reserved.
WHO classificationWHO classification
Adenocarcinoma – intestinal type
– diffuse type
Adenocarcinoma – intestinal type
– diffuse type
Papillary
Tubular
Mucinous
Signet ring cell
Adenosquamous
Squamous cell
Small cell
Undifferentiated
Papillary
Tubular
Mucinous
Signet ring cell
Adenosquamous
Squamous cell
Small cell
Undifferentiated
© 2004, 2002 Elsevier Inc. All rights reserved.
Pathogenesis..Pathogenesis..
Multistep progression, from chronic gastritis to intestinal metaplasia, dysplasia, and carcinoma
Multistep progression, from chronic gastritis to intestinal metaplasia, dysplasia, and carcinoma
© 2004, 2002 Elsevier Inc. All rights reserved.
Pathogenesis…..diffuse typePathogenesis…..diffuse type
CDH1 mutation : E-cadherin– Familial
– 50% of sporadic type
Methylation of CDH1 promoter.
BRCA2 mutation.
CDH1 mutation : E-cadherin– Familial
– 50% of sporadic type
Methylation of CDH1 promoter.
BRCA2 mutation.
© 2004, 2002 Elsevier Inc. All rights reserved.
Pathogenesis…..intestinal typePathogenesis…..intestinal type
FAP individual in Japan
Mutation in β-catenin. MSI
Hyper-methylation of several genes like TGFβ RII, BAX, IGFRII, p16/INK4a.
FAP individual in Japan
Mutation in β-catenin. MSI
Hyper-methylation of several genes like TGFβ RII, BAX, IGFRII, p16/INK4a.
© 2004, 2002 Elsevier Inc. All rights reserved.
Others are also there…Others are also there…
Genetic variants of pro-inflammatory and immune response genes specially in H.pylori
IL-1β
TNF
IL-10
IL-8
Toll-like receptor 4 (TLR4)
Genetic variants of pro-inflammatory and immune response genes specially in H.pylori
IL-1β
TNF
IL-10
IL-8
Toll-like receptor 4 (TLR4)
© 2004, 2002 Elsevier Inc. All rights reserved.
Morphology -Location Morphology -Location
Gastric antrum.
Lesser curvature.
Gastric antrum.
Lesser curvature.
© 2004, 2002 Elsevier Inc. All rights reserved.
Type Type
Intestinal
Diffuse
Intestinal
Diffuse
© 2004, 2002 Elsevier Inc. All rights reserved.
Intestinal type- grossIntestinal type- gross
© 2004, 2002 Elsevier Inc. All rights reserved.
Intestinal type- microscopyIntestinal type- microscopy
© 2004, 2002 Elsevier Inc. All rights reserved.
Intestinal typeIntestinal type
Composed of glandular structures.
Columnar and mucin secreting.
Grow along broad cohesive fronts to form either an – Exophytic mass.
– Ulcerated area.
Composed of glandular structures.
Columnar and mucin secreting.
Grow along broad cohesive fronts to form either an – Exophytic mass.
– Ulcerated area.
Calcification
Stroma of the tumor is heavily infiltrated by neutrophils or histiocytes
Calcification
Stroma of the tumor is heavily infiltrated by neutrophils or histiocytes
© 2004, 2002 Elsevier Inc. All rights reserved.
Intestinal type- microscopyIntestinal type- microscopy
© 2004, 2002 Elsevier Inc. All rights reserved.
Diffuse type- grossDiffuse type- gross
© 2004, 2002 Elsevier Inc. All rights reserved.
Diffuse type- microscopyDiffuse type- microscopy
© 2004, 2002 Elsevier Inc. All rights reserved.
Diffuse type-microscopyDiffuse type-microscopy
Extensive fibrosis
Inflammation
Most tumor cells grow individually
Mucin is intracytoplasmic, typical signet ring.
Extensive fibrosis
Inflammation
Most tumor cells grow individually
Mucin is intracytoplasmic, typical signet ring.
© 2004, 2002 Elsevier Inc. All rights reserved.
Linitus plastica- leather bottle stomach..Linitus plastica- leather bottle stomach..
Desmoplastic
Diffuse rugal flattening and a rigid, thickened wall
Desmoplastic
Diffuse rugal flattening and a rigid, thickened wall
© 2004, 2002 Elsevier Inc. All rights reserved.
C /FeatureC /Feature
Median age- 55 years
Male: female :: 2 : 1
remarkable decrease in gastric cancer incidence applies only to the intestinal type
weight loss, abdominal pain, nausea, vomiting.
Median age- 55 years
Male: female :: 2 : 1
remarkable decrease in gastric cancer incidence applies only to the intestinal type
weight loss, abdominal pain, nausea, vomiting.
© 2004, 2002 Elsevier Inc. All rights reserved.
Spread Spread
supraclavicular nodes (Virchow’s node)
periumbilical region --- subcutaneous nodule---- Sister Mary Joseph nodule.
Locally invades– esophagus, duodenum
– colon, pancreas, spleen
– omentum,
– seeding of peritoneum , lung/liver
supraclavicular nodes (Virchow’s node)
periumbilical region --- subcutaneous nodule---- Sister Mary Joseph nodule.
Locally invades– esophagus, duodenum
– colon, pancreas, spleen
– omentum,
– seeding of peritoneum , lung/liver
© 2004, 2002 Elsevier Inc. All rights reserved.
Virchow’s nodeVirchow’s node
© 2004, 2002 Elsevier Inc. All rights reserved.
Sister Mary Joseph noduleSister Mary Joseph nodule
© 2004, 2002 Elsevier Inc. All rights reserved.
Kruckenberg tumorKruckenberg tumor
metastases of diffuse or signet ring types to one or both ovaries
metastases of diffuse or signet ring types to one or both ovaries
© 2004, 2002 Elsevier Inc. All rights reserved.
Prognosis depends on..Prognosis depends on..
Depth of invasion
Extent of nodal involvement
Distant metastasis
Depth of invasion
Extent of nodal involvement
Distant metastasis
© 2004, 2002 Elsevier Inc. All rights reserved.
GASTRIC LYMPHOMA GASTRIC LYMPHOMA
© 2004, 2002 Elsevier Inc. All rights reserved.
Epidemiology Epidemiology
Extra-nodal lymphomas --- GI tract
--- the stomach
Allogeneic bone marrow transplant
Organ transplant recipients– MALTomas
– Diffuse large b-cell lymphoma
Extra-nodal lymphomas --- GI tract
--- the stomach
Allogeneic bone marrow transplant
Organ transplant recipients– MALTomas
– Diffuse large b-cell lymphoma
© 2004, 2002 Elsevier Inc. All rights reserved.
Pathogenesis Pathogenesis
Preexisting MALT
Pro-lymphomatous lesion like Chronic H.pylori infection
Eradication of the infection with antibiotics
MALToma may turn into DLBCL
Preexisting MALT
Pro-lymphomatous lesion like Chronic H.pylori infection
Eradication of the infection with antibiotics
MALToma may turn into DLBCL
© 2004, 2002 Elsevier Inc. All rights reserved.
TranslocationsTranslocations
Translocations are
11;18
1;14
14;18
activation of NF-κB
Translocations are
11;18
1;14
14;18
activation of NF-κB
In DLBCL transformation p53, p16 inactivation are there.
In DLBCL transformation p53, p16 inactivation are there.
© 2004, 2002 Elsevier Inc. All rights reserved.
Microscopy Microscopy
Dense lymphocytic infiltrate in the lamina propria
Dense lymphocytic infiltrate in the lamina propria
The neoplastic lymphocytes infiltrate the gastric glands focally to create diagnostic Lymphoepithelial Lesions
The neoplastic lymphocytes infiltrate the gastric glands focally to create diagnostic Lymphoepithelial Lesions
© 2004, 2002 Elsevier Inc. All rights reserved.
© 2004, 2002 Elsevier Inc. All rights reserved.
GISTGIST
© 2004, 2002 Elsevier Inc. All rights reserved.
Morphology Morphology
© 2004, 2002 Elsevier Inc. All rights reserved.
Carney’s triadCarney’s triad
gastric GIST, paraganglioma, and pulmonary chondroma
gastric GIST, paraganglioma, and pulmonary chondroma