A short description of stomach cancer covering the incidence, risk factors, classification, clinical presentation, and management.

1. CA STOMACH

2. Incidence
• Fifth most common malignancy worldwide*
• Twice more common in males than females
• Mean Age: 63 years ( above 40 years)
• Site:
*source: eClinicalMedicine

3. Risk Factors
DIETARY AND
ENVIRIONENTAL
FACTORS
PRE-CANCEROUS
CONDITIONS
FAMILIAL AND GENETIC
FACTORS

4. Risk Factors
• Red Meat
• Spices
• Salt-fish
• Smoked Salmon
• Smoking
• Polycyclic hydrocarbons
• Alcohol
• Low carb High fat Diet
DIETARY AND
ENVIRIONENTAL FACTORS

5. Risk Factors
• Atrophic Gastritis
• Pernicious Anaemia
(4-6X more risk)
• Hypogammaglobulinemia
• H pylori infection
• Adenomatous polyps
(20% malignant transformation)
• Menetrier’s Disease
• Gastric Ulcer
• Previous Gastric Resection
PRE-CANCEROUS
CONDITIONS

6. Risk Factors
• E-Cadherin Mutation: 60-90% RISK
• 10% patients = Family history
• Blood Group Association: A+
( due to different mucopolysaccharide secretion and increased susceptibility to
ingested carcinogens)
• Diagnosed <40 years of age
FAMILIAL AND GENETIC
FACTORS

7. Risk Factors
Proximal Cancer
• Obesity
• High Socioeconomic group
• Group A Gastritis
• More Aggressive
• More Advanced stage
Distal Cancer
• Assn with H pylori Infection
• Low Socioeconomic group
• Group B Gastritis
• Less Aggressive

8. Pathogenesis
Normal
Gastric
Mucosa
Superficial
Gastritis
Chronic
Inflammation
Atrophic
Gastritis
Metaplasia Dysplasia Cancer
• H. Pylori
• Smoking
• High salt
• Low Vitamin C
• High Nitrates
• High pH
• Bacterial
Overgrowth
• Chronic inflammation
• Carcinogens
• Reactive oxygen
species
Reversible Irreversible

9. Classification
• Lauren’s Classification {Pathological Classification}
• Japanese Classification {Early Gastric Cancer}
• Bormann’s Classification {Advanced Gastric Cancer}
• WHO classification
• Molecular Classification

10. Lauren’s Classification
INTESTINAL DIFFUSE
Environmental Familial
Gastric Atrophy, Intestinal Metaplasia Blood type A
Male> Female Female> Male
Increase incidence with Age Younger Age group
Gland formation Poorly differentiated signet ring cells
hematogenous spread Lymphatic spread
APC gene mutation Decrease E Cadherin, CDH gene

11. Japanese Classification
For Early cancers
Type I Exophytic lesion extending into the gastric
lumen
Type II
(superficial
variant)
II A Elevated lesions with a height no more
than the thickness of the adjacent mucosa
II B Flat lesions
II C Depressed lesions with an eroded but not
deeply ulcerated appearance
Type III Excavated lesions that may extend into the
muscularis propria without invasion of this layer
by actual cancer cells

12. Bormann’s Classification
For Advanced Cancer
type I polypoid or fungating lesions
type II ulcerating lesions surrounded by elevated borders
type III ulcerating lesions with infiltration into the gastric
wall
type IV diffusely infiltrating lesions
(LINITIS PLASTICA)
type V lesions that do not fit into any of the other
categories.

13. WHO Classification
1. Adenocarcinoma (95%): Papillary, tubular
Mucinous
Signet ring
2. Adenosquamous cell carcinoma
3. Squamous cell carcinoma
4. Undifferentiated carcinoma
5. Unclassified carcinoma

14. Molecular Classification
1. Micro-Satellite Instability type (MSI)- BEST prognosis
2. Epstein-Barr Virus type (EBV)
3. Chromosomal Instability type(CIN)
4. Genomically Stable type (GS)- WORST prognosis

15. Clinical Presentation
L. O. A. D. S.
L.= Lump: Hard and irregular lump
O.= Outlet Obstruction: cancer is most common cause of gastric outlet obstruction.
A.= Anemia: Achlorhydria causes poor conversion of Ferrous to ferric, resulting in anemia
D.= Dyspepsia
S.= Silent Presentation. Pt have vague symptoms: early satiety, flatulence, discomfort,
pain abdomen, weight loss

16. Atypical Presentations
1. Sister Mary Joseph Nodules: Peri-umblical metastasis
2. Krukenberg Tumor: Bilateral ovarian metastasis
3. Irish Nodule: left axillary node
4. Blumer Shelf: Metastasis to pelvis/ Pouch of Douglas
5. Virchow’s Node: Left Supraclavicular node
6. Trosseau syndrome: Migratory thrombophlebitis
7. Lesser Trelat sign: Multiple seborrheic keratosis
8. Tripe Palms: Hyperkeratotic palms

18. Investigations
1. CBC: may indicate Anemia (microcytic hypochromic anemia)-20% cases
2. Endoscopy (Oesophagogastroduodenoscopy)
1. To know the extent of lesion
2. To confirm diagnosis
3. To take biopsy
3. USG and CT Scan: to rule out secondaries in liver
4. Endoscopic USG: to differentiate between early and advanced cancer
5. CEA (Carcinoembryonic Antigen): elevated in 60-70% cases
6. Barium Meal: used as screening tool in Japan
not done nowadays due to availability of endoscopy

19. TNM Staging
Primary Tumor (T)
Tx Primary Tumor cannot be assessed
T0 No evidence of primary tumor
Tis CA in situ
TI
A Tumor invades the lamina propria/ muscularis mucosae
B Tumor invades the submucosa
T2 Tumor invades the muscularis
T3 Tumor penetrates the subserosal C.t without invasion of visceral
peritoneum/ adjacent structures
T4
A Tumor invades visceral peritoneum (serosa)
B Tumor invades adjoining structures

20. TNM Staging
Regional Lymph Nodes (N)
Nx Regional Lymph Nodes cannot be assessed
N0 No Regional lymph node metastasis
N1 Metastasis in 1-2 regional lymph nodes
N2 Metastasis in 3-6 regional lymph nodes
N3
A Metastasis in 7-15 regional lymph nodes
B Metastasis in >16 regional lymph nodes
Distant Metastasis (M)
M0 No distant metastasis
M1 Positive peritoneal cytology/ Distant metastasis +

21. Treatment
SURGICAL MGMT
• Primary tumor
resection
• Lymph node
resection
CHEMOTHERAPY
1. 5-fluorouracil & Cisplatin
• Node+ cases
• Advned cancer
2. Neoadjuvant chemo
• to stage down tumor in
T3&T4 disease
RADIOTHERAPY
Given at gastric bed, to
prevent local recurrence
after surgery
MULTIMODAL
TREATMENT

22. Primary Resection of Tumor
• Distal Gastrectomy
• Partial/Subtotal Gastrectomy
• Total Gastrectomy

23. Distal Gastrectomy
• Proximal margin: 5cm
• Distal margin: Pylorus
(irrespective of site of cancer)
Stomach removed: 30%
Tumor Site: Pylorus/ Antrum of stomach
Reconstruction: Bilroth II

24. Partial/Subtotal Gastrectomy
• Proximal margin: 5cm
• Distal margin: Pylorus
(irrespective of site of cancer)
Reconstruction: Roux en Y
Gastrojejunostomy
Tumor Site: Body of stomach
Stomach removed: 60-70%

25. Total Gastrectomy
Reconstruction: esophago-jejunal
anastomosis
Tumor Site: Fundus/ distal to gastro-
esophageal junction (Siewart type 3)
Stomach removed: 100%

26. R- Resections
R Resection
Ro describes a microscopically margin-negative resection,
in which no gross or microscopic tumour remains in the
tumour bed.
R1 indicates removal of all macroscopic disease but
microscopic margins are positive for tumour.
R2 indicates gross residual disease.

27. Lymph node Clearance
Lymph node clearance
D1 Resection removal of primary group of nodes
such as nodes along the lesser and
greater curvature, and
juxtapyloric nodes (stations 1-6)
D2 Resection removal of lymph nodes such as
left gastric, common hepatic,
splenic, retropancreatic nodes
(stations 7-12a)
D3 Resection removal of lymph nodes such as
para-aortic, porta hepatis nodes
(>12 stations)