Oncology

Benign stomach tumors

Lecture: Benign stomach tumors

By Professor: Armine Andryan
Ministry of Health<Disease control and prevention
National Center> SNCO "Shirak" Branch Deputy Director,
Coordinator of Epidemiology
Benign stomach tumors
Benign stomach tumors are epithelial (polyps and
polyposis) and non-epithelial.
Stomach polyps are often located in the antral region
(about 80%). Glandular (adenomatous),
angiomatous, granulation polyps are distinguished.
There are different opinions about the malignancy
of gastric polyps: it varies widely (5-60%).
Malignant transformation of a polyp often begins at
its base: a wide base, a solid (cartilaginous)
consistency, the presence of ulceration in the center
or near the base are typical macroscopic signs of
polyp malignancy.
Benign stomach tumors
Clinical picture
The diagnosis
The treatment

Clinical picture.
• pains in the epigastric region
• they block the gastric outlet - vomiting
• Prolapse of long-legged polyps duodenum – severe cramping pains
• Ulceration of the polyp - gastric bleeding
• polyp malignancy - loss of appetite, general weakness, weight loss
The diagnosis
• X-ray examination – round or oval filling defect with clear smooth borders,
mucosa is not altered, peristalsis is preserved
• gastroscopy – biopsy
The treatment
• unique polyps (up to 1.5 cm in diameter) without malignancy (confirmed by
gastrobiopsy) - dynamic control
• malignancy - gastric resection with removal of regional lymph nodes
• multiple polyps – subtotal gastric resection or gastrectomy.
Benign stomach tumors
Non-epithelial benign tumors
Non-epithelial benign tumors - myomas,
fibromas, hemangiomas, lymphangiomas,
neurinomas, neurofibromas, osteomas,
osteochondromas, hamartomas, etc. are
also found.
They are mainly located in the submucous
and muscle layers or under the cornea.
Grow endogastrically, exogastrically,
mixed.
Benign stomach tumors
Clinical picture
The diagnosis
Treatment

Clinical picture. • pains – of varying intensity, constant

and short-term • in the case of ulceration, bleeding -
hidden or intense, life-threatening • dyspeptic
phenomena, • palpation of the tumor
The diagnosis • X-ray examination – filling defect,
mucosal folds are displaced, peristalsis is preserved in
most cases. • gastroscopy+biopsy
Treatment. is surgical, in case of endogastric tumors
gastric resection is performed, in case of small exogastric
tumors wedge-shaped gastric resection is performed.
Stomach cancer
Stomach cancer occupies one of the highest places in the
structure of morbidity and mortality of malignant
neoplasms. It accounts for about 50% of gastrointestinal
tumors and about 12.3% of tumors from other locations.
According to statistical calculations, about 800,000 new
cases of stomach cancer (9.9%) and about 600,000
deaths (12.1%) are recorded annually on earth. The
countries with the highest incidence of stomach cancer
are Japan, Chile, Finland, Iceland.
Stomach cancer is mostly observed in middle and old age -
40-60 years old. Men get sick about 2 times more often
than women.
Stomach cancer
Risk factors for the development of stomach cancer
are:
• nutritional characteristics - intake of high-calorie,
smoked, hot food, irregular eating, high amounts
of salt, preservatives, unrefined (animal) fats in
food, insufficient intake of foods and fruits rich in
vitamins and microelements,
• smoking,
• excessive use of alcohol,
• high amount of nitrates in water and soil (Japan,
Chile).
Stomach cancer
Precancerous diseases. • stomach polyps (adenomatous polyps)
and polyposis (obligate precancerous), • chronic gastritis
(atrophic and hypertrophic), • chronic stomach ulcer
(malignancy in 2-25% of cases), • Menetriei's disease, as a
variant of hypertrophic gastritis, stomach cancer develops in 8-
40% of patients. • pernicious anemia (B12-deficiency anemia
can be one of the symptoms of stomach malignancy, on the
other hand, in Addison-Birmer disease, stomach cancer
develops about 8 times more often than in healthy people), •
gastric resections (resections) for any reason, including benign
tumors, can have a carcinogenic effect, which is associated with
a decrease in gastric acidity, the development of atypical
microflora and mucosal metaplasia after these operations; in
this case, stomach cancer develops after an average of 15-20
years.
Stomach cancer
The relationship between the incidence of stomach cancer and
Helicobacter pylori infection has been proven. According to
the International Union Against Cancer (UICC, 1994),
Helicobacter pylori is considered a definitive (definite,
group I) biological carcinogen because: • causes
pronounced infiltrative gastritis, atrophic processes,
proliferation of interstitial cells and intestinal metaplasia, •
contributes to the colonization of other microbes, which
produce endogenous carcinogens - nitrosocompounds in
low acidity conditions; cagA oncogene is present in 60% of
microorganism strains, • interferes with the synthesis of
ascorbic acid, which inhibits the conversion of nitrates into
nitrites and the formation of nitrosoamines,
Stomach cancer
• contributes to the methylation of cytosines, as a result of
which the function of the suppressor gene, p53, is
disturbed. • shows synergism with dietary salt in the
development of gastric cancer. The importance of heredity
is also not excluded (the example of Napoleon Bonaparte).
People with blood type A(II) have a 20% higher incidence
of stomach cancer than the rest. The most frequent
location of gastric cancer is the antral region (60-70% of
gastric cancer cases), in 10-15% of cases it is located in
the lesser curvature, 8-10% in the gastric inlet, 2-5% in the
anterior and posterior walls, 1% in of the greater curvature
of the stomach, 1% - in the region of the bottom of the
stomach, 3-5% are observed total damage to the stomach.
Stomach cancer
In case of early gastric cancer, the tumor process is limited by damage to
the mucosa and submucosa of the stomach wall. There are 4
anatomical forms of stomach cancer (Borman-Konechnoi
classification).
1. Polyposis tumors (mushroom, 6-10%),
2. Plaque-ulcer cancer (15-20%).
3. Ulcer-infiltrative cancer (60%)
4. Diffuse cancer (5-10%).
Histological classification of gastric cancer (WHO, 1977)
5. adenocarcinoma (95% of cases) o papillary o tubular o mucinosis o
Ring-celled
6. undifferentiated cancer
7. adenocancroid
8. squamous cell carcinoma
9. unclassifiable cancer
Stomach cancer
There are 3 ways of spread of stomach cancer
1. by the walls of the stomach (local spread),
2. lymphogenic with lymphatic vessels and nodes (mostly, 45-65%).
3. hematogenous with blood vessels.
The intra-organ spread of stomach cancer proceeds by the type of
infiltration, especially towards the cardia, where the main flow of
lymph is directed. Penetrating all layers of the stomach walls, the tumor
invades neighboring organs and tissues (pancreas, left lobe of the liver,
transverse colon and its mesentery).
Metastasis through the lymphatic channels is observed most often and the
paragastric lymph nodes are mainly affected, which according to location
are:
4. retropyloric lymph nodes,
5. small fat lymph nodes in the region of a.gastrica sinistra,
6. large fat lymph nodes,
7. lymph nodes of the splenic stem.
Stomach cancer
Distant metastases are of importance to the clinician
1. Virchow's node (Virchow's node or Troisier's sign) - metastasis in the
left upper lobe, as a result of the spread of cancer cells through the
thoracic duct;
2. Metastases in the ovaries (Krukenberg's metastasis), which are caused by
the transfer of tumor cells from the stomach through the post-abdominal
lymphatic channels with retrograde flow (some authors explain the
occurrence of these metastases by implantation), are often bilateral and
can sometimes be mistaken for primary ovarian tumors;
3. Schnitzler's metastasis (Blumer's shelf) - metastasis of implantation
nature Abdominal rectovesical in men, rectovaginal in women in the pit;
4. Metastasis in the port (Sister Mary Joseph node) - retrograde metastasis,
tumor cells penetrate through the round ligament of the liver.
Hematogenous metastases occur in the liver (most often, about 30% of
cases), pancreas, lungs, bones, kidneys, adrenal glands, central nervous
system.
Stomach cancer
The exit of the tumor to the surface of the
peritoneum opens a path of implantation
metastasis by transferring the cells to
neighboring organs, a carcinomatosis of
the peritoneum occurs in the form of a
small papular rash, which leads to the
development of ascites.
Stomach cancer
Classification of gastric cancer according to the TNM system
(7th edition, 2009)
T- primary tumor.
Tx – primary tumor cannot be assessed,
T0 - absence of signs of primary tumor,
Tis - pre-invasive cancer - carcinoma in situ
T1a – the tumor invades the lamina propria of the stomach wall
T1b – the tumor invades the stomach wall to the submucosa layer
T2 – the tumor invades the muscle layer of the stomach wall
T3 – the tumor invades the submucosal layer of the stomach wall
T4a – the tumor invades the lining of the stomach wall
T4b – the tumor has spread to neighboring structures
Stomach cancer
N – regional lymph nodes
Nx – data insufficient to evaluate regional lymph nodes
N0 - there are no metastatic lesions of the regional lymph nodes the signs
N1 – metastases are present in 1-2 regional lymph nodes
N2 – metastases are present in 3-6 regional lymph nodes
N3a – metastases are present in 7-15 regional lymph nodes
N3b – metastases are present in more than 16 regional lymph nodes
M – distant metastases
cM0 – clinically there are no signs of distant metastases
cM1 – distant metastases are clinically present
pTNM postoperative histopathological classification Categories pT, pN and pM
correspond to categories T, N and M.
G degree of histological differentiation (differentiation).
Gx – grade of differentiation not determined
G1 – high degree of differentiation
G2 – medium degree of differentiation
G3 – low degree of differentiation
G4 – undifferentiated tumor
Stomach cancer
 Խմբավորումը ըստ փուլերի
 0 stage Tis N0 M0
 IA stage T1 N0 M0
 IB stage T1 N1 M0
 T2 N0 M0
 IIA stage T1 N2 M0
 T2 N1 M0
 T3 N0 M0
 IIB stage T4a N0 M0
 T3 N1 M0
 T2 N2 M0
 T1 N3 M0
 IIIA stage T4a N1 M0
 T2 N3 M0
 T3 N2 M0
 IIIB stage T3 N3 M0
 T4a N2 M0
 T4b N0, 1 M0
 IIIC stage T4a N3 M0
 T4b N2, 3 M0
 IV stage any Pt any N M1
Stomach cancer
Clinical picture
Clinical picture Symptoms of the local nature of stomach cancer are
pain and dyspeptic disorders.
The pain is mainly located in the epigastric region and does not have
a characteristic radiation, but in cases of inflammation (for
example, in the case of invasion of the pancreas, liver) it can
radiate to the lumbar and back regions. The nature of the pain is
different, it can occur immediately after eating or 2-3 hours later.
Absence of periodicity of pain.
Dyspeptic syndrome is manifested by nausea, a feeling of heaviness
in the epigastric region after eating, constipation, vomiting (with
eaten food or stomach contents, bloody). Vomiting can occur in all
locations of stomach cancer, but it is most often and particularly
persistent and persistent in cancer of the gastric outlet (the motor-
evacuator function of the stomach is disturbed).
Stomach cancer
Clinical picture
Dysphagia develops in the case of damage to
the cardiac part of the stomach. In the case
of damage to the fundal part of the stomach,
hematopoietic function is disturbed and the
development of unexplained anemia
(anemia) is possible. During palpation of
the abdomen, it is also possible to palpate
the tumor in the epigastric region. Common
symptoms may include general weakness,
loss of appetite, weight loss, etc.
Stomach cancer
The diagnosis
The diagnosis. • X-ray examination - "filling defect" with uneven borders,
interruption of the folds of the mucous membrane ("malignant relief of
the mucous membrane"), rigidity of the wall (disruption of peristalsis in
the given area), significant obstruction of permeability; in the case of the
ulcer-infiltrative form, in the case of radiographically detectable "niche",
unlike the "niche" of ulcer disease, the borders do not go beyond the
borders of the stomach; • ultrasound examination, •
fibroesophagogastroscopy - enables detecting changes in the gastric
mucosa with a diameter smaller than 0.5 cm, determining the intra-organ
distribution and performing a biopsy for the purpose of diagnosis
verification; detected during gastroscopy
 exophytic tumor,
 hardened ulcer with cushion-like edges and uneven surface,
 infiltrated gray-white rigid part of the mucous membrane; • computer
tomography of the organs of the abdominal cavity, • endoscopic
ultrasound examination (EUS), • laparoscopy (peritoneoscopy).
Stomach cancer
Differential diagnosis
Complications of stomach cancer

Differential diagnosis. • stomach ulcer disease •

gastritis • benign stomach tumors (polyps)
Complications of stomach cancer. 1. bleeding (8-
10%) - is one of the most terrible complications; 2.
perforation of the stomach wall, which leads to the
development of widespread purulent peritonitis; 3.
Tumor ingrowth into neighboring organs - can
cause pain, jaundice, as a result of ingrowth into the
large intestine, a gastrointestinal tract is formed; 4.
stenoses of gastric outlet and gastric inlet.
Stomach cancer
Treatment
Treatment. The main type of radical treatment of stomach
cancer is the surgical method. Gastric cancer is an absolute
indication for surgery. The radicality of the operation
provides: 1. Resection of the stomach, duodenum and rumen
within healthy tissues 2. the groups of lymph nodes (D1 and
D2) that may be affected by the given location of cancer are
removed in one block with the stomach; 3. antiblastic
surgery, that is, a complex of tricks is used, aimed at
reducing the possibility of so-called manipulative
dissemination.
In case of exophytic carcinomas of the pyloroantral region of
the stomach, which do not extend in the proximal direction
above the level of the angle of the stomach, a distal subtotal
resection of the stomach is performed.
Stomach cancer
Treatment
Proximal subtotal gastrectomy is performed for exophytic
tumors of the gastric cardia (which does not extend distal
to the border of the upper third of the lesser curvature of
the stomach), exophytic tumors of the gastric floor and
upper third of the greater curvature.
Gastrectomy is indicated for exophytic gastric body tumor,
total involvement, or infiltrative tumor of any location.
In the absence of tumor invasion of neighboring organs
(large colon, pancreas, spleen, left lobe of the liver) and
absence of distant metastases, combined operations are
performed: subtotal resection of the stomach or
gastrectomy with removal of a part of the neighboring
organ or resection in one block.
Stomach cancer
Treatment
Palliative and symptomatic surgeries are
divided into 3 groups.
1. palliative resections of the stomach,
2. bypass anastomoses (gastroentero-,
esophagojejuno-, esophagofundoanatomoses),
3. feeding tubes (gastrostomy, jejunostomy).
Drug treatment of gastric cancer (5-
fluorouracil, fluorofur, doxorubicin,
mitomycin C, cisplatin, etoposide) is mainly
performed as an adjuvant.