Gastric Cancer Matt White AM Report April 19, 2010.
-
Upload
agnes-dawson -
Category
Documents
-
view
225 -
download
5
Transcript of Gastric Cancer Matt White AM Report April 19, 2010.
![Page 1: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/1.jpg)
Gastric Cancer
Matt White
AM Report
April 19, 2010
![Page 2: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/2.jpg)
Objectives
Epidemiology Clinical Presentation Diagnosis Staging Treatment Screening
![Page 3: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/3.jpg)
Objectives
Epidemiology Clinical Presentation Diagnosis Staging Treatment Screening
![Page 4: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/4.jpg)
Epidemiology
Incidence: 21,260 cases in 2007 – ~7 per 100,000
11,210 cancer deaths in 2007 Mortality significantly decreased in past 75
years (unknown reasons)
![Page 5: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/5.jpg)
Gastric tumors
85% adenoocarcinomas 15% lymphomas and gastrointestinal stromal
tumors (GIST)
![Page 6: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/6.jpg)
Adenocarcinoma Cancer types
“Intestinal type” (more common)– Morphologically similar to intestinal
adenocarcinomas.
Diffuse-type– Lack of intercellular adhesions (germline mutation
in protein E-cadherin)
![Page 7: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/7.jpg)
Spectrum of gastric cancer
Proposed progression: chronic gastritis -->
– chronic atrophic gastritis --> intestinal metaplasia -->
– dysplasia --> adenocarcinoma
![Page 8: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/8.jpg)
Risk Factors for gastric cancer
Diet– nitroso compounds– low fruit/vegetable, high fried foods/processed meat– High salt intake
Obesity Smoking (HR 2-3) ? Alcohol H. Pylori Low socioeconomic status Hereditary diffuse gastric cancer
– 40-67% lifetime risk for men, 60-83% for women Immigrants from endemic areas
– maintain native country risk, risk to offspring similar to new homeland
![Page 9: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/9.jpg)
Objectives
Epidemiology Clinical Presentation Diagnosis Staging Treatment Screening
![Page 10: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/10.jpg)
Presentation
Approximately 50% of cases present with symptoms and have disease extending beyond locoregional confines
Of locoregional cases, only ½ can undergo a potentially curative resection
![Page 11: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/11.jpg)
Symptoms at presentation
![Page 12: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/12.jpg)
Symptoms (cont’d)
Dysphagia: more common with proximal gastric tumors
Occult GI bleeding very common, overt bleeding <20%.
![Page 13: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/13.jpg)
Less Common Symptoms
Pseudoachalasia: if Auerbach’s plexus involved
Colonic obstruction: if cancer spreads (direct extension) to colonic wall
![Page 14: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/14.jpg)
Signs
Palpable abdominal mass: most common physical finding
If cancer spreads via lymphatics…– Left supraclavicular node (Virchow’s)– Periumbilical node (Sister Mary Joseph)– Left axillary node (Irish)– Enlarged ovary (Krukenberg's tumor)– Ascites
![Page 15: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/15.jpg)
Objectives
Epidemiology Clinical Presentation Diagnosis Staging Treatment Screening
![Page 16: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/16.jpg)
Diagnosis
EGD– Gold standard– Single biopsy from ulcer -> sensitivity ~ 70%– Seven biopsies from ulcer -> sensitivity >98%– Brush cytology increases sensitivity of single
biopsies, aid in multiple biopsies unclear
![Page 17: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/17.jpg)
Barium studies
False negative in as many as 50% of cases Sensitivity as low as 14% in early cases May be superior to EGD for linitis plastica
– EGD may be normal while “leather-bottle” will be apparent on radiograph
![Page 18: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/18.jpg)
Linitis Plastica
Diffuse-type gastric cancer Tumor often infiltrates the submucosa and
muscularis propria Superficial biopsies may be falsely negative Combination of strip and bite biopsy needed
if suspicious for linitis plastica
![Page 19: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/19.jpg)
Linitis Plastica, “leather bottle stomach”
![Page 20: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/20.jpg)
Objectives
Epidemiology Clinical Presentation Diagnosis Staging Treatment Screening
![Page 21: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/21.jpg)
Staging of Gastric Cancer
Two systems: – Japanese classification (more elaborate and
anatomic based)– Western: developed by American Joint Committee
on Cancer (AJCC) and International Union Against Cancer (UICC) -- more widely used
Tumors at GE junction of in cardia of stomach within 5cm of GE junction– Classified using esophageal staging
![Page 22: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/22.jpg)
Other caveats
T stage: dependent on depth of tumor invasion NOT size of lesion
Nodal stage: based on # of positive LN rather than location of LNs (proximity to tumor)
![Page 23: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/23.jpg)
Staging workup
Biopsy Imaging
– CT: evaluates for metastases (M stage) 20-30% with negative CT have intraperitoneal disease at
laparatomy Accuracy of 50-70% for T stage Slightly worse accuracy for N stage compared to EUS
– EUS: most reliable nonsurgical method to evaluate depth of invasion
More accurate than CT for T stage 65-90% accurate for N stage
![Page 24: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/24.jpg)
Staging workup
PET– More sensitive than CT for detection of distant
metastases. – Also useful for detecting LNs– Negative PET not helpful- even large tumors can
be falsely negative if metabolic activity low. Most diffuse gastric cancers (signet ring) are not FDG
avid
![Page 25: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/25.jpg)
Staging workup
Serologic markers– CEA, CA-125, CA 19-9, CA 72-4 may be elevated
but have low sensitivity/specificity– None are diagnostic– Preoperative elevation in markers usually
pretends high risk of adverse outcome– No serologic finding should exclude surgical
consideration
![Page 26: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/26.jpg)
AJCC Staging System
![Page 27: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/27.jpg)
AJCC Staging System
![Page 28: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/28.jpg)
Objectives
Epidemiology Clinical Presentation Diagnosis Staging Treatment Screening
![Page 29: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/29.jpg)
Treatment
Locoregional (stage I-III) disease– Potentially curable– Refer for multidisciplinary evaluation and
consideration of surgery
Advanced (stage IV) disease– Palliative therapy– Studies indicate longer survival and better quality
of life with systemic treatment
![Page 30: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/30.jpg)
Treatment
Complete surgical resection with removal of LNs (only chance of cure)– Possible in < 1/3 of cases
Subtotal gastrectomy for distal carcinomas, total or near-total for proximal masses
Reduction of tumor bulk (palliative)– Chemotherapy (cisplatin + 5-FU or irinotecan)
Partial response in 30-50% of patients
– Radiation (for pain control, no mortality benefit with XRT alone)
![Page 31: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/31.jpg)
Data from SEER. Patients diagnosed from 1991-2000 (n=14,097). Stage IA (n=1194), stage IB (n=655), stage IIA (n=1161) stage IIB (n=1195), stage IIIA (n=1031), stage IIIB (n=1660), stage IIIC (n=1053), stage IV (n=6148).
![Page 32: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/32.jpg)
PrognosisStage TNM Features
% of Cases*
% 5-year survival*
0 TisN0M0 Node negative; limited to mucosa 1 90
IA T1N0M0Node negative; invasion of lamina propria or
submucosa 7 59
IB T2N0M0Node negative; invasion of muscularis
propria 10 44
II
T1N2M0 Node positive; invasion beyond mucosa but within wall 17 29T2N1M0
T3N0M0 Node negative; extension through wall
IIIAT2N2M0 Node positive; invasion of muscularis propria
or through wall 21 15T3N1-2M0
IIIB T4N0-1M0Node negative; adherence to surrounding
tissue 14 9
IV T4N2M0Node negative; adherence to surrounding
tissue 30 3Any M1 Distant Metastases
** Data from American Cancer Society
![Page 33: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/33.jpg)
Objectives
Epidemiology Clinical Presentation Diagnosis Staging Treatment Screening/Follow-up
![Page 34: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/34.jpg)
Screening
Currently screening programs in Japan, Venezuela, Chile due to high incidence
– Mostly barium studies, EGD is concerning findings– Some use serum pepsinogen testing for high risk with EGD
confirmation– H. pylori: sensitivity 88%, specificity 41% (Japan)– Japan study: 5-year survival 74-80 in screened group, 46-
56% for non-screened group. Not cost effective in US due to relatively low
incidence (<10 per 100,000)– Preventing incidence of 1 gastric cancer death estimated to
cost $247,600
![Page 35: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/35.jpg)
Gastric Ulcers
25% of patient with gastric cancer have history of a gastric ulcer
American Society of Gastrointestinal Endoscopy recommendations:
– Follow-up EGD in 8-12 weeks to verify healing. – Non-healing ulcers need repeat biopsies
Question of cost-effectiveness of repeat endoscopies; however, small (curable) lesions may be missed without follow-up.
![Page 36: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/36.jpg)
Take Home Points
Most cases present in advanced stage Staging workup (CT vs PET vs EUS) to
evaluate extent of disease Staging laparoscopy indicated for medically
fit patients with >T1 lesion and without stage IV disease
Ensure follow-up of ulcers seen on EGD No effective screening in US patients
![Page 37: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/37.jpg)
References
Harrison’s Principles of Internal Medicine Up to Date
![Page 38: Gastric Cancer Matt White AM Report April 19, 2010.](https://reader035.fdocuments.us/reader035/viewer/2022062304/56649dbe5503460f94ab0db4/html5/thumbnails/38.jpg)