Gastric cancer
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Transcript of Gastric cancer
Gastric Cancer
Dr. Amina Abdul RahmanJunior ResidentDept. of Radiotherapy
Epidemiology Anatomy Classification Pathology Clinical Features Staging Prognosis
Gastric Cancer
Epidemiology
Fourth most common cancer in the world Second most common cause of cancer
related death Marked geographic variation High risk areas : Japan, Korea, Latin
America, USSR Low risk areas: USA, Israel, Kuwait, Canada
Epidemiology
Geographic Variations in Incidence
Over all Global decline in Gastric Ca
But the incidence of proximal gastric cancers is increasing in the west…
Sub site specific incidence in the UK
The Trend in our Hospital
Most common site was Antrum 48% 40% was found to be in the body 10% was found to be in the proximal
stomach
Cardia Vs Non Cardia Cancers
GEJ TumorsCardia
Tumors
Risk factors for Gastric Cancer
Acquired High salt consumptionHigh nitrate consumptionPoor food preparation (smoked, salt cured)Lack of refrigerationDiet low in Vit A and CSmoking, heavy alcohol consumption
Helicobacter pylori 3 to 6 times increase in risk of gastric
cancer intestinal type of cancer in the distal
stomach Decreases acid production causing chronic
atrophic gastritis
Risk factors for Gastric Cancer
Radiation exposure
Prior Gastric surgery for benign ulcer disease
Risk factors for Gastric Cancer
Genetic FactorsType A blood groupPernicious anemiaFamily historyHNPCCLi-Fraumeni syndromePeutz Jegher SyndromeBRCA2 mutation
Risk factors for Gastric Cancer
Fresh fruits and vegetables
NSAIDs
Protective Factors
CDH1mutation
Codes for E-Cadherin
Prophylactic gastrectomy
Hereditary Diffuse Gastric Cancer
Proximal Gastric Cancer Distal Gastric Cancers
Includes GEJ, Tumors of the Cardia Includes Body and Antrum
Rapidly increasing incidence in the west
World wide incidence is declining steadily
Mainly diffuse type Mainly intestinal type
M:F = 1:1 M>F
Younger age Older age
More aggressive Less aggressive
More in the developed countries More in developing countries
Not associated with H. pylori Associated with H. pylori
Associated with GERD Associated with atrophic gastritis
Proximal Vs Distal cancers
ANATOMY
ANATOMY
The Stomach
Relations of the Stomach
Arterial supply of the Stomach
Venous drainage of the Stomach
Lymphatic Drainage
Lymphatic Drainage of the Stomach
Lymph Node Station 1 to 6
Lymph node stations 7 to 11
12 – Hepatoduodenal ligament13 – On the posterior surface of the head of pancreas14 – Root of mesentery15 – Para aortic16 - Paracolic
Lymph node stations 12 to 16
Stomach layers
Histology of Stomach layers
Classification of Gastric Tumors
Siewert’s Classification of GEJType I : Adeno Ca Distal Esophagus, infilt GEJ from above
Type II : Adeno Ca of the real cardia, true GEJ
Type III : Subcardial Gastric Adenoca, infilt GEJ from above
Early Gastric Cancer• T1a and T1b, any N
Advanced Gastric Cancer• T2 and above
Japanese classification of EGC
Borrmann classification
PATHOLOGY
WHO Classification• On histologic appearance alone
Lauren’s Classification• Histology and morphology
PATHOLOGY
Epithelial tumorsAdenocarcinomaSmall cell carcinomaCarcinoid tumor
Malignant LymphomaMaltomaMantle cell lymphomaDLBCL
WHO Classification
Non epithelial tumorsLeiomyomaSchwannomaGranular cell tumorLeiomyosarcomaGISTKaposi Sarcoma
WHO Classification
ADENOCARCINOMA Tubular Papillary Mucinous Signet ring cell carcinoma Undifferentiated
Pathology
Intestinal type• 54%
Diffuse type• 32%
Lauren’s classification
Form exophytic or ulcerated growth More in the distal stomach Due to H. pylori This type is declining worldwide Older patients with a male preponderance M:F = 2:1 Better prognosis Form glandular elements in histology
Intestinal type
Intestinal type
Chronic atrophic gastritis
Intestinal metaplasia
Dysplasia
Carcinoma in situ
Intestinal type
Mainly affects cardia Form infiltrative lesions No precancerous lesions Loss of CDH1 gene Discohesive cells that do not form glands Signet ring cells Younger age, M = F Worse prognosis
Diffuse Type
Diffuse type
Her2-neu amplification in 12 to 27% More in intestinal type than diffuse type Prognostic significance has not been
identified 4 tier scoring Trastuzumab in Her2-neu 3+ or FISH
positive locally advanced or metastatic stomach cancer
Immunohistochemistry
CLINICAL FEATURES
Lesions of proximal stomach – Dysphagia Diffuse infiltrative lesions produce early
satiety Gastric outlet obstruction Trousseau sign Blumer’s Shelf Virchow’s node (Troisier’s sign) Irish node Sister Mary Joseph Nodule
CLINICAL FEATURES
Adjacent organ invasion
Hematogenous spread
Peritoneal Seeding: Krukenberg tumor Blumer Shelf Lymphatic spread: Virchow’s node (Troisier’s sign) Irish node
ROUTES OF SPREAD
TNM Staging
T Staging
N0 : No regional lymph node metastases N1 : 1to 6 regional lymph node metastases N2 : 7 to 15 regional lymph node metastases N3 : More than 15 regional lymph node
metastases
N Staging
Involving Lymph node stations 12 onwards Omental deposits Positive peritoneal cytology
M Staging
Prognostic Factors
Age Sex Primary tumor Site Lauren Classification Number of Positive and Negative lymph
nodes Depth of invasion
Prognostic Nomogram
Disease specific survival
To Be Continued….