Management of Gastric Cancer

Girmaye Tamrat,M.D.

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 Objectives
1.To outline the epidemiology & risk factors
for Gastric cancer
2.To describe the pathogenesis &
premalignant lesions in Gastric Ca
3.To discuss the clinical presentation &
work-up of patients with Gastric Ca
4.To outline the pathologic sub-types &
staging of Gastric Ca
5.To describe the Management of patients
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with Gastric Ca
 Introduction
 Most common &lethal cancer
 Significant geographical , ethnic & socio-
economic differences in distribution
 difficult to diagnose and to cure
 Late presentation & advanced Disease
 High recurrence even if resected

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 Epidemiology
• ~870,000 new cases & 650,000 deaths per
Yr world wide
• Incidence has declined rapidly world wide
 Recognition of some risk factors
 Popularization of refrigerators
• Incidence varies with different geographic
regions
 Highest in Eastern Asia, South America &
Eastern Europe
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 Epidemiology(Cont…)
• Race
 Substantial difference in incidence among
different ethnic groups in the same region
• Sex
 Slightly more Males than Females(2:1)

• Age
 Most are Elderly

• Peak age 60-70yrs

• Histological pattern
 A decline in the intestinal type compared with
the diffuse type
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 Pathogenesis of Gastric Ca
• According to Lauren’s classification
 2 distinct types of Gastric Ca
A. Intestinal Type (Well differentiated)
B. Diffuse Type (Un differentiated)
• Both have
 Distinct morphologic appearance,
 Pathogenesis
 Genetic profiles

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 Risk Factors
A . Environmental Risk Factors
1.Diet
A. Nitrates in preserved smoked food
 Increased Gastric nitrite has been observed in

• Intestinal metaplasia , dysplasia & gastric

Ca
B . Salt: High salt intake damages stomach
mucosa
 Induces inflammation ,associated with

increased DNA synthesis & cell proliferation

 Increases susceptibility to carcinogenesis

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 Risk Factors(Cont…)
2. Smoking
• Risk increases by 1.5X
• Higher in Men
3. Socio economic status
 Risk of distal gastric ca:2X increased with low socio
economic class
 Proximal gastric ca : more in higher socio economic
class
4. Gastric Surgery
• Hypochlorhydria , Secondary hypergastrinemia &
bile reflux(Bilroth II)
• Risk is greatest 15-20 years after the surgery
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 Risk Factors(Cont…)
5. Reproductive Hormones
• Incidence is low in females
• Reproductive hormones in females may be
protective
6. EBV : Associated with 5-10% of gastric ca
world wide
7. H-Pylori Infection
• Classified as Group I or definite carcinogen by WHO
• Is most common cause of Gastritis
• Leads to Atrophy & intestinal metaplasia
• 6x with 100% infection
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 Risk Factors(Cont…)
B. Host Related Risk Factors
1. Blood Group
 Blood group A: 20% excess of Gastric Ca

 Particularly Assd with the Diffuse type

 Due to effects of genes closely assd with blood group Ags

2. Familial predisposition
 Genetic predisposition: repeatedly confirmed

 Certain risks have been identified

 a. Clustering of H-Pylori infn with in families

 b. Genetic predisposition for Chronic Atrophic Gastritis

 c. In association with certain cancer syndromes

 HNPC,FAP Li-Fraumeni syndrome

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 Risk Factors(Cont…)
3. Gastric polyps
• Adenomatous type
4. Gastric Ulcer(1.8x)
• Commonly with Gastric ulcer & not with duodenal
ulcer
• Risk significantly increased with
• Persistent H-Pylori infection
• Higher Grade of base line gastric mucosal atrophy &
• Older Age
5. Pernicious Anemia
• Due to Autoimmune Atrophic Gastritis
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increased risk of intestinal type 11
Gross Morphology & Histologic Sub-
types
1. Gross appearance of pathology specimens
A. Ulcerative
B. Polypoid
C. Schirrhous (Diffuse Linitis Plastica)
D. Superficial Spreading
E. Multicentric
F. Barrett Ectopic Adenocarcinoma
2. Histologic Sub-types
1. Adenocarcinomas (Tubular , Papillary , Mucinous , Signet-
ring or Undeferentiated)(95%)
2. Lymphomas(4%)
3. Stromal Tumors(1%)
4. Carcinoid tumors
5. Adenoacanthomas
6. SCC
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 Clinical Presentation
1. History
 Weight loss and anorexia------95%
 Nausea, Abdominal pain & early satiety
• Due to tumor mass
 Dysphagia
 Melena or Haematemesis
• In <20% of patients
 Pseudoachalasia Syndrome
• Involvement of Auerbach’s plexus or
• Due to malignant Obstn at G-E junction

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 Clinical Presentation(Cont…)
2. Physical Signs
• Most Signs indicate an advanced disease
• Epigastric mass
• Virchow’s Node
• Sister Mary Joseph’s Node
• Peritoneal spread
 Krukenberg’s tumor (Enlarged Ovary)
• Blumer’s shelf
• Ascites
• A palpable liver mass
• Jaundice, Colonic Obstruction
• Feculent Emesis: Gastro colic fistula
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 Work Up
1. Lab Studies
• CBC: To R/O Anemia
• Electrolyte’s & LFT
• Serologic markers
 Carcino -embryonic Ag (CEA)

• Increased in 45-50% of cases

 Cancer Antigen(CA19-9)

• Increased in 20% of the cases

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 Work Up(Cont…)
2. Upper GI- Endoscopy
 More sensitive & specific
 Tissue Diagnosis & Anatomical localization
 ≈50% of malignant ulcers appear benign grossly
 Single Biopsy: 70% sensitivity
• Brush cytology may increase sensitivity
 7 biopsies: From ulcer margin & base
• Increases sensitivity to 98%
• Diagnosing Linitis plastica may be difficult
• Mucosal Biopsies may be falsely negative b/c
submucosa is affected

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 Work Up(Cont…)
3. Endoscopic U/S
 Precise in staging & assessing depth of invasion or
involvement of adjacent structures
4. Barium Studies
 Can identify both malignant ulcers & infiltrative
lesions
 As high as 50% false negativity in early cases
 ≈75% accuracy
 In LINITIS PLASTICA
• Barium meal may be superior than Endoscopy
• Decreased distensibility , stiff, “Leather-Flask” appearing

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 Work Up(Cont…)
5. Abdomino -pelvic CT
• Done after settling the Diagnosis
• Secondaries <5mm may be missed
• Sensitivity limited if L.N. size is<8mm
• Only 50-70% accuracy in assessing T-stage of the
Disease
• False positive if inflammatory LAP present
6. PET Scan(Positron-Emission
Tomogram)
• Using 18-flurodeoxy glucose
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More sensitive than CT in detecting distant spread 18
 Work Up(Cont…)
7. CXR
• To R/O metastatic lesions
8. Staging Laparascopy
• More sensitive than CT & EUS
• Can directly see Liver surface, peritoneum& Local
LNs
9. Histo -pathology
• Tells us the histological sub-type

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 Patterns Of Spread
1.Direct extension
• Omentum
• Pancreas
• Diaphragm
• Transverse Colon , Meso- Colon
2. Lymphatic spread
3. Hematogenous spread
4. Transperitoneal spread

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 Staging
 Staging Systems
 2 Major Classifications

1. Japanese Classification(Based on L.N

stations)
2. TNM staging
• T-Stage: Dependent on depth of

invasion ,not size

• N-Stage: Based on # of positive L.Ns

rather than proximity of L.Ns to the

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 TNM-Staging

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 Treatment
• Surgical Vs Medical Rx
 Surgery is the only curative Rx

 Provides the best palliation

 Provides the most accurate staging

• Preoperative Mx
 Once Dx is established evaluate the extent of

Ds
1. Operative Mx
Extent of Gastric resection
 Total Gastrectomy
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 Operative Mx(Cont…)
• Extent of Gastric resection
 Is site Dependent
 Focuses on complete removal of the gastric Ca
• 4-5cm margin from the gross edge of the
tumor
 For Distal lesions
• Distal Subtotal Gastrectomy (Regardless of
T-Stage)

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 Operative Mx(Cont…)
 For Proximal Gastric Ca & True G-E junction
Ca
 Proximal Gastrectomy with Esophago-
gastrostomy
 Some prefer Total Gastrectomy
 For Mid body or more extensive lesions
 Total Gastrectomy required
 For more distal lesions
 Sub-total Gastrectomy is preferred approach

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 Operative Mx(Cont…)
• Total Gastrectomy
 Increased Mortality & Morbidity
 Does not have survival benefit
• Proximal Resections
 Appear to have similar perioperative
Morbidity/Mortality to total gastrectomy
• Extended Organ Resection
 Reserved for Node negative T4 lesions
 Invaded portions of the Diaphragm

,Pancreas
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 Operative Treatment Cont…)
 Options of reconstruction
 Billroth I
 Billroth II
 In Ante-colic fashion
 Entero - enterostomy may be
performed on surgeons preference
 Roux-en- Y
 To avoid post operative reflux
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 5Year survival rates
 Stage0 : >90%
 Stage Ia: 60-80%
 StageIb: 50-60%
 Stage II: 30-40%
 Stage IIIA: 20%
 Stage IIIb: 10%
 Stage IV: <5%

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 Local Palliation For Advanced
Gastric Ca
• Majority of patients require palliation at
some point in the course of the illness
• Palliative Rx for advanced Ds can be either
LOCAL or SYSTEMIC
• Cytotoxic Chemo Rx: Most effective for
metastatic Ds, inadequate for local Syms
• Locally advanced OR Locally recurrent Ds
requires multidisciplinary MX
 Endoscopic
 Surgical
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 Radiotherapy or Other approaches
 Local Palliation For Advanced
Gastric Ca (Cont…)
• Palliative resection(Gastrectomy)/Bypass
 May provide symptomatic relief
 Pain
 Nausea
 Bleeding
 Obstruction
 Perforation
• Non-Surgical Palliation
A. Endoscopic stent placement : For obstructive Syms
B. Radiation Rx : To control pain , bleeding , or
obstruction
C. Endoscopic Laser Rx : To palliate dysphagia due to
obstruction
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