Gastric Cancer

Gastric Cancer
Professor Dr.
Bedii Berat APAYDIN
Epidemiology of Gastric Cancer
 Gastric ca. is the 13th most common & the 10th
most deadly cancer in US
 Japan, Chile, China, Iceland & Finland have a high
rate of incidence & death from this malignancy
 Its true incidence has declined by more than
40 % in the last 30 years in the US
 Its world wide frequency has albeit diminished
less dramatically
 Decline in mortality rate in Japan in the past
years has been the result of mass screening
 Location of the cancers has shifted from the distal
to the proximal portion of the stomac
 Is 2 times more common in men than in women
 Its incidence & mortality increase with age (>50)
Risk Factors for Gastric Cancer
 Heredity
 Age
 Gender
 Diet
 Social habits
 Occupation
 Predisposing conditions
 H.pylori
 Hypogammaglobulinemia
Heredity
 The fact that the incidence in Japan, Chili
Iceland & Finland is 5-6 times as great as
those in other parts of the world, support
racial differences
 Certain families have demonstrated
multiple occurences of Gastric cancer:
Napoleon Bonaparte
 4 % of patients with gastric cancer have a
family history of gastric cancer
 Patients with gastric cancer have
frequently blood group A
Diet
 Foods high in sodium such as pickled
vegetables, salted fishes & meat
 Smoked foods
 High fat
 Items containing nitrite & nitrate
 Elevated zinc level in the water
 Gastric cancer is inversely associated with

consumption of fresh vegetable, citrous
fruits, vitamine C & whole milk
 Refrigeration has contributed to the decline
of Gastric Cancer
Social Habits
Cigarette smoking
is associated with an increased
risk for Gastric Cancer
Social & Occupational Factors
 Lower socioeconomic class
 Coal mining
 Timber processing
 Rubber production
 Fishermen
 Ceramic workers
 Textile workers
 Painters
 Asbesto exposure
have been associated with gastric ca.
Predisposing Conditions
 Chronic atrophic gastritis & intestinal
metaplasia
 Helicobacter pylori infection
 Gastric polyps
 Previous gastrectomy
 Pernicious anemia
 Hypertrophic gastropathy (Menetrier
disease)
have been associated with Gastric ca
Microscopic Pathology
 With only the rare exceptions of
carcinoids & squamous carcinomas,
gastric cancers are all adenocancer
 The WHO’s histologic classification
recognizes 4 patterns of adenocancer:
- papillar - mucinous
- tubular - signet ring cell
 The most widely used histopathologic
classification is described by Lauren
Lauren’s Classification of Gastric ca.
Intestinal type: Diffuse type:
 Cells of this type forme  Is composed of
glands resembling colonic
glands dispersed cells which
are not organized in
 Manifested by polipoid glandular pattern
mass or ulceration  It infiltrates stomach
 Occurs usually in wall without forming
geographic areas where mass & produces linitis
gastric ca incidence is plastica
high: worldwide  It is endemic
distrubition is epidemic
 Associated with atrophic  It is less associated
gastritis,intestinal with dietary factors
metaplasia & with diet  It is found in young & in
induced dysplastic women
changes  Has a greater tendency
 Occurs more often in men for peritoneal spreading
& in patients over age 60
 Metastasizes to the liver
Early Gastric Cancer
Gastric ca. confined to mucosa or submucosa
regardless of lymph node involvement
 EGC ranges from 8-25 % in USA &
35-50 % all of gastric ca in Japan
 70 % of EGC are well differentiated & 30 %
are poorly differentiated & lymph node
invasion is less than 5 %
 5 year survival is 99 % when cancer is
confined to the mucosa, 90 % when cancer
is confined to the submucosa & survival
drops to 70 % when lymph node
involvement is present
 EGC is divided to several types & subtypes
Advanced Gastric Cancer
 Gross morphology of advanced gastric ca.
(tumor extending beyond the submucosa)
is classified by BORMANN
 Bormann classification includes 4 distinct gross

categories
 (%13) Type 1 polypoid

 (%25) Type 2 ulcerating with sharply defined margins
 (%36) Type 3 combined ulcerating & infiltrating
without clear cut margins
 (%26) Type 4 infiltrating
(%11) 4a : superficial spreading
(%15) 4b: linitis plastica
Symptoms of Gastric Cancer
 Diagnosis is not made until there is an extensive
involvement of the gastric wall & adjacent viscera
 Initial symptoms are vague postprandial heaviness &
epigastric discomfort not different from other dyspeptic
symptoms
 Anorexia -especially for beef products & smoking- with
weight loss (6 kg) are the most common signs
 At the beginning, patients complaint from epigastric pain
which mimic peptic ulcer & responds transiently to medical
therapy, persistent pain is a late complaint
 Constipation frequently results from restricted foods
 Anemia findings (fatigue & weakness) & occult blood in the
stool are common whereas massive bleeding occurs in
less than 5 % of the patients
 Nausea & vomiting occur when distal lesions obstruct
pylorus, dysphagia occurs when cancer arises from cardia
Signs of Gastric Cancer
 Anemia findings
 Palpable abdominal mass is common: 50 %
 Abdominal tenderness is a rare finding
 Hepatomegaly suggests metastatic spread
 Peritoneal seeding may cause massive
ascites or Krukenberg’s tumor (involvement
of ovaries) or Blummer’s shelf (involvement
of Douglas)
 A palpable lymph node in the left
supraclavicular fossa (Wirchow’s node) & a
metastatic deposit to the umblicus (Sister
Joseph’s nodule) are sings of advanced
disease
Laboratory Studies
 A microcytic anemia secondary to
chronic GI bleeding or macrocytic anemia
secondary to preexisting pernicious
anemia can be found
 Abnormal liver function tests suggest
liver metastasis
 CEA, CA19-9, α feto protein levels are
commonly elevated
 Studies of gastric acid secretion often
reveal achlorhydria or hypochlorhydria
 Serum gastrin level is elevated secondary
to achlorhydria
Radiologic Studies
 Single contrast barium study of the upper GI
tract is the first diagnostic study to evaluate
symptoms.This study detects more than 80% of
gastric ca., but it frequently misses early ca.
 Findings indicating gastric ca. are as follows:
 A mass lesion in the gastric lumen
 An obtructing lesion of the antrum and cardia
 An ulcerated mass resembling a bening ulcer
 Enlarged gastric folds
 Nondistendible stomach
 Early gastric ca. can be diagnosed by double-
contrast barium study
Endoscopic Evaluation
 Upper GI endoscopy enables the direct
visualisation,photograpic documentation
& biopsy of gastric lesions
 Visual diagnosis is accurate in 90% of
patients with gastric ca. but biopsies
must be done for histologic confirmation
 A minimum of 6 biopsy samples should
be obtained
 In infiltrative type of gastric ca. diagnosis
was made by biopsy in only 50% of
patients
Preoperative Staging
 Once the diagnosis of gastric ca. has been
established, the extent of disease & its
resectability should be evaluated
 CT or MRI scans should be obtained to evaluate

hepatic metastasis, extansion of tm into
contiguous organs (pancreas, transverse
mesocolon)
 Endoscopic intraluminal US provides accurate

information about the depth of penetration of tm
 Laparoscopy can be used to detect small

intraperitoneal & liver metastasis not seen on CT
Spread of Gastric Cancer
 Intramural spread
 Direct invasion
 Metastasis by way of lymphatic
vessels
 Metastasis by way of blood
vessels
 Implantation onto peritoneal
surfaces
Treatment of Gastric Cancer
 Surgical therapy is the only curative treatment
 85% of patients are operable
 In 50% of patients, lesions are amenable to
resection
 Of the resectable lesions, half are potentially
curable
 The surgical objective is to remove the tumor,
an adjacent uninvolved margin of stomach,
the regional lymph nodes & if necessary
portions of involved adjacent organs
 Japanese surgeons recommend more agressive
lymphadenectomy as a matter of routine in the
resection of ca
For 1/3 distal stomach tumors
Resection would entail distal gastrectomy
(proximal margin should be a minimum of
6 cm from the gross tumor), with en bloc
removal of omentum, a 3-4 cm cuff of
duodenum & regional lymph nodes
(N1+N2 LN), LN12, LN13, LN16
For 1/3 middle stomach tumors &
multifocal tumors &
linitis plastica
• Total gastrectomy
• Splenectomy (if required)
• Omentectomy
• N1+N2 lymphadenectomy
(LN1-12 complete)
For 1/3 proximal stomach
cancer
• Proximal gastrectomy
• Distal esophagectomy (10 cm)
• Pancreas preserved Splenectomy 10)
• LN 1-10
• LN16
Palliative Surgical Therapy
Palliative resection is recommended if

• the stomach is movable &
• life expectancy is more than 2
months
• Gastrojejunostomy can be done
when resection is not feasible

Gastric Cancer

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Gastric Cancer

 Gastric cancer is inversely associated with

 Bormann classification includes 4 distinct gross

 (%13) Type 1 polypoid

 CT or MRI scans should be obtained to evaluate

 Endoscopic intraluminal US provides accurate

 Laparoscopy can be used to detect small

Palliative resection is recommended if

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