lect 4-gastric tumors

Gastric Gastric TumorsTumors

SMS 2044SMS 2044

GASTRIC CANCERGASTRIC CANCERGASTRIC CANCERGASTRIC CANCER

Gastric cancer is the second most Gastric cancer is the second most common fatal cancer in the world common fatal cancer in the world with high frequency in Japan.with high frequency in Japan.

(after lung cancer)(after lung cancer)

The disease presents most The disease presents most commonly in the 5commonly in the 5thth and 6 and 6thth decades decades of life and affect males twice as of life and affect males twice as often as females.often as females.

Contn…

Gastric Cancer

Epidemiology

Forth common types of cancer

Second most common cancer related death

Geographic variations (ten times)

Continuing decline

Primarily a decline of distal GC

(2000) (2000)

TUMORSTUMORS The gastrointestinal tract tumors arising from the The gastrointestinal tract tumors arising from the

mucosa mucosa predominate predominate overover mesenchymalmesenchymal tumors.tumors.

Parenchyma is a term used to describe a bulk of a Parenchyma is a term used to describe a bulk of a substance and it is the substance and it is the functionalfunctional part part of an organ in the of an organ in the body.body.

This is in contrast to the This is in contrast to the stroma, stroma, which refers to the which refers to the structuralstructural tissue tissue of organs, being exactly, connective of organs, being exactly, connective tissues.tissues.

The cause of the disease multistep The cause of the disease multistep process but several predisposing process but several predisposing factors attributed to cause the factors attributed to cause the disease :disease :

a.a. EnvironmentEnvironment e.e. Atrophic gastritisAtrophic gastritis b.b. DietDiet f.f. Chronic gastric Chronic gastric

ulcerulcer c.c. HeredityHeredity g.g. Adenomatous Adenomatous

polypspolyps d.d. AchlorhydriaAchlorhydria i.i. H. Pyloric colonisationH. Pyloric colonisation

Gastric Cancer

Environmental factors

H. pylori Genetic factors

Etiological Factors of Gastric Cancer

Precancerous changes

TYPES OF GASTRIC CANCER:TYPES OF GASTRIC CANCER:

AA..Benign TumoursBenign Tumours

BB..Malignant Malignant TumoursTumours

The benign groups includes:-The benign groups includes:-

1.1. Non-neoplastic gastric polypsNon-neoplastic gastric polyps

2.2. AdenomasAdenomas

3.3. Neoplastic gastric polypsNeoplastic gastric polyps

4.4. Smooth muscles tumours benignSmooth muscles tumours benign (Leiomyomas)(Leiomyomas)

55.. Polyposis Syndrome Polyposis Syndrome (eg:- Polyposis (eg:- Polyposis coli, coli,

Juvenile polyps and P.J. Syndrome) Juvenile polyps and P.J. Syndrome)

6.6. Other benign tumours are fibromas, Other benign tumours are fibromas, neurofibromas, aberrat pancreas andneurofibromas, aberrat pancreas and

angiomas.angiomas.

Gastric TumorsGastric Tumors These are broadly classified These are broadly classified into polyps and carcinoma.into polyps and carcinoma.

Gastric Polyps Gastric Polyps The term The term "polyp" "polyp" is applied to any nodule or mass that is applied to any nodule or mass that

projects above the level of the surrounding mucosa. projects above the level of the surrounding mucosa.

Occasionally, a Occasionally, a lipoma or leiomyoma lipoma or leiomyoma arising in the wall arising in the wall of the stomach may protrude from under the mucosa to of the stomach may protrude from under the mucosa to produce an apparent produce an apparent polypoidpolypoid lesion. lesion.

However, However, the use of the term the use of the term "polyp" "polyp" in the in the gastrointestinal tract is generally restricted to mass gastrointestinal tract is generally restricted to mass lesions arising in the mucosa.lesions arising in the mucosa.

Hyperplastic polyps arise from an exuberant Hyperplastic polyps arise from an exuberant reparative response to chronic mucosal damage and reparative response to chronic mucosal damage and hence are composed of a hence are composed of a hyperplastichyperplastic mucosal mucosal epithelium and an epithelium and an inflamed edematous stromainflamed edematous stroma..

They are not true neoplasms.They are not true neoplasms. Fundic gland polyps Fundic gland polyps are small collections of dilated are small collections of dilated

corpus-type glands thought to be small corpus-type glands thought to be small hamartomas.hamartomas.

On the other hand, the less common adenomas On the other hand, the less common adenomas contain contain dysplastic epitheliumdysplastic epithelium. .

As with colonic adenomas, adenomas are true As with colonic adenomas, adenomas are true neoplasms.neoplasms.

MORPHOLOGY

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HistoologyHistoologyHistopathology report of a gastric polyp should

comment on the following:Histological features of the polyp: Presence of cystic dilatation Lining epithelium of the cyst Presence of muscle fibres in the lamina propria Inflammatory inflltrate ( Eg. presence of eosinophils). Presence of muscle fibres in the lamina propria.Presence of muscle fibres in the lamina propria. Presence or absence of dysplasia or malignancy in case of

Neoplastic.

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PATHOLOGY OF GASTRIC (MALIGNANT) TUMOURS:

PATHOLOGY OF GASTRIC (MALIGNANT) TUMOURS:

The gastric cancer may arise The gastric cancer may arise in the antrum (50%), the in the antrum (50%), the gastric body (30%), the gastric body (30%), the fundus or oesophago-gastric fundus or oesophago-gastric juntion (20%).juntion (20%).

TypesTypes ofof MalignantMalignant TumoursTumours::

a.a. AdenocarcinomaAdenocarcinoma

b.b. LeiomyosarcomaLeiomyosarcoma

c.c. LymphomasLymphomas

d.d. Carcinoid TumoursCarcinoid Tumours

Pathohistologic classificationPathohistologic classification

HistologyHistologyAdenocarcinoma Adenocarcinoma 90%90%

Lymphoma Lymphoma 5%5%

Stromal Stromal 2%2%

Carcinoid Carcinoid <1%<1%

Metastasis Metastasis <1%<1%

Adenosquamous/squamous Adenosquamous/squamous <1%<1%

Miscellaneous Miscellaneous <1%<1%

Early Gastric Cancer:Early Gastric Cancer: Defined as Defined as cancer whichcancer which is is confined to the confined to the mucosa mucosa and and submucosa submucosa regard-regardless of less of lymph nodes status. lymph nodes status.

Advanced Gastric CancerAdvanced Gastric Cancer: : Defined Defined as tumor that has as tumor that has

involved involved the the muscularis muscularis propria of the propria of the stomach wallstomach wall. .

1.1. Polypoid or ProliferativePolypoid or Proliferative

2.2. UlceratingUlcerating

3.3. Ulcerating/InfiltratingUlcerating/Infiltrating

4.4. Diffuse Infiltrating (Linnitus-Diffuse Infiltrating (Linnitus-

Plastica)Plastica)

The macroscopic forms of gastric cancers are

classified by (Bormann classification) into:-

Carcinoma of the stomachCarcinoma of the stomach

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PathogenesisPathogenesisVast majority are Vast majority are

adenocarcinomasadenocarcinomasArise on background of Arise on background of

chronic gastritis, chronic gastritis, intestinal metaplasia, intestinal metaplasia, dysplasiadysplasia

Most cases advanced at Most cases advanced at presentationpresentation

PathogenesisPathogenesis

• The major factors thought to affect the genesis of this The major factors thought to affect the genesis of this form of cancer areform of cancer are

• Environmental.Environmental.

• Risk factors for the increasingly more common Risk factors for the increasingly more common diffuse carcinoma are largely unknown, although diffuse carcinoma are largely unknown, although germ-line mutations in E-cadherin leading to an germ-line mutations in E-cadherin leading to an autosomal dominant inheritance of diffuse gastric autosomal dominant inheritance of diffuse gastric carcinoma.carcinoma.

• E-cadherin (epithelial)E-cadherin (epithelial), , also known as also known as CDH1CDH1, is a , is a human human genegene. CDH1 has also been designated as. CDH1 has also been designated as

• Chronic gastritis associated with Chronic gastritis associated with H. pyloriH. pylori infection infection remains a major risk factor for gastric carcinoma. remains a major risk factor for gastric carcinoma.

• A recent prospective study from Japan has A recent prospective study from Japan has underscored the relationship between underscored the relationship between H. pyloriH. pylori infection and gastric cancer. infection and gastric cancer.

• The risk is particularly high in those with chronic The risk is particularly high in those with chronic gastritis limited to the gastric antrum. gastritis limited to the gastric antrum.

• These patients develop severe gastric atrophy, These patients develop severe gastric atrophy, intestinal metaplasia, and ultimately dysplasia and intestinal metaplasia, and ultimately dysplasia and cancer.cancer.

• Perhaps chronic inflammation generates DNA-Perhaps chronic inflammation generates DNA-damaging free radicals, and the resulting mutations damaging free radicals, and the resulting mutations lead to hyperproliferation that is not balanced by lead to hyperproliferation that is not balanced by apoptosis. Much remains to be known.apoptosis. Much remains to be known.

The location of gastric carcinomas within the stomach is as The location of gastric carcinomas within the stomach is as follows: follows:

• pylorus and antrum, 50% to 60%;pylorus and antrum, 50% to 60%;• cardia, 25%; cardia, 25%; • and the remainder in the body and fundus. and the remainder in the body and fundus.

The lesser curvature is involved in about 40% and the greater The lesser curvature is involved in about 40% and the greater curvature in 12%. curvature in 12%. Thus, Thus, a favored location is the lesser a favored location is the lesser curvature of the antropyloric regioncurvature of the antropyloric region..

Although less frequent, an ulcerative lesion on the greater Although less frequent, an ulcerative lesion on the greater curvature is more likely to be malignant.curvature is more likely to be malignant.

Gastric carcinoma is classified on the basis of depth of Gastric carcinoma is classified on the basis of depth of invasion, macroscopic growth pattern, and histologic subtype.invasion, macroscopic growth pattern, and histologic subtype.

MORPHOLOGY

The morphologic feature having the greatest impact on clinical outcome is the depth of invasion.

Early gastric carcinoma is defined as a lesion confined to the mucosa and submucosa, regardless of the presence or absence of perigastric lymph node metastases.

I. ProtrudedIIA. Superficial-elevatedIIB. Superficial-flatIIC. Superficial-depressedIII. Excavated

Advanced gastric carcinoma is a neoplasm that has extended below the submucosa into the muscular wall and has perhaps spread more widely.

I. Polypoid or fungatingII. ExcavatingIII. Ulcerated and infiltratingIV. Infiltrating (diffuse thickening)

Gastric mucosal dysplasia is the presumed precursor lesion of early gastric cancer, which then in turn progresses to "advanced" lesions.

Ulcerative gastric carcinoma. The ulcer is large with irregular, heaped-up margins.

There is extensive excavation of the gastric mucosa with a necrotic gray area in the deepest portion. Compare with the benign peptic ulcer

The three macroscopic growth patterns of gastric carcinoma, which may be evident at both the early and advanced stages, are (1) Exophytic, with protrusion of a tumor mass into the lumen; (2) flat or depressed, in which there is no obvious tumor mass within the mucosa; and(3) Excavated, whereby a shallow or deeply erosive crater is present in the wall of the stomach.

Exophytic tumors may contain portions of an adenoma. Exophytic tumors may contain portions of an adenoma. Flat or depressed malignancy presents only as regional Flat or depressed malignancy presents only as regional

effacement of the normal surface mucosal pattern.effacement of the normal surface mucosal pattern. Excavated cancers may mimic, in size and appearance, Excavated cancers may mimic, in size and appearance,

chronic peptic ulcers, although more advanced cases exhibit chronic peptic ulcers, although more advanced cases exhibit heaped-up margins .heaped-up margins .

Uncommonly, a broad region of the gastric wall, or the entire Uncommonly, a broad region of the gastric wall, or the entire stomach, is extensively infiltrated by malignancy. stomach, is extensively infiltrated by malignancy.

The rigid and thickened stomach is termed a The rigid and thickened stomach is termed a leather bottle leather bottle stomach,stomach, or or linitis plastica;linitis plastica;

metastatic carcinoma from the breast and lung may generate metastatic carcinoma from the breast and lung may generate a similar picture. a similar picture.

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The Histologic appearances The Histologic appearances of gastric cancer have been of gastric cancer have been variously subclassified, but the two most important types are variously subclassified, but the two most important types are the the intestinal type and diffuse type intestinal type and diffuse type ..

The The intestinal variantintestinal variant is composed of malignant cells forming is composed of malignant cells forming neoplastic intestinal glands resembling those of neoplastic intestinal glands resembling those of colonic colonic adenocarcinoma.adenocarcinoma.

TheThe diffuse variantdiffuse variant is composed of gastric-type mucous cells is composed of gastric-type mucous cells that generally do not form glands but rather permeate the that generally do not form glands but rather permeate the mucosa and wall as scattered individual "mucosa and wall as scattered individual "signet-ring" cells or cells or small clusters in an "infiltrative" growth pattern. small clusters in an "infiltrative" growth pattern.

Histologic appearances

MicroscopyMicroscopy

Intestinal type (forms Intestinal type (forms glands – like cancers of glands – like cancers of colon and oesophagus)colon and oesophagus)

Diffuse type – Diffuse type – dissociated tumour cells dissociated tumour cells often containing a often containing a mucinous “blob” – signet mucinous “blob” – signet ring cellsring cells

HistopathologyHistopathology Adenocarcinomas tend to aggressively invade the gastric Adenocarcinomas tend to aggressively invade the gastric

wall, infiltrating the wall, infiltrating the muscularis mucosaemuscularis mucosae, the submucosa, and , the submucosa, and thence the thence the muscularis propria. muscularis propria.

Intestinal typeIntestinal type adenocarcinoma tumor cells describe adenocarcinoma tumor cells describe irregular tubular structuresirregular tubular structures, harboring pluristratification, , harboring pluristratification, multiple lumens, reduced stroma ("back to back" aspect).multiple lumens, reduced stroma ("back to back" aspect).

Often, it associates Often, it associates intestinal metaplasia intestinal metaplasia in neighboring in neighboring mucosa.mucosa.

Depending on glandular architecture, cellular Depending on glandular architecture, cellular pleomorphism pleomorphism and mucosecretion, adenocarcinoma may present 3 degrees and mucosecretion, adenocarcinoma may present 3 degrees of differentiation: well, moderate and poorly differentiated.of differentiation: well, moderate and poorly differentiated.

chronic chronic atrophic gastritisatrophic gastritis, retained glandular structure, little , retained glandular structure, little invasiveness, and a sharp margin.invasiveness, and a sharp margin.

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HistopathologyHistopathology Diffuse type Diffuse type adenocarcinoma (mucinous, colloid, linitis adenocarcinoma (mucinous, colloid, linitis

plastica, leather-bottle stomach) plastica, leather-bottle stomach) Tumor cells are discohesive and secrete mucus which is Tumor cells are discohesive and secrete mucus which is

delivered in the interstitium producing large pools of delivered in the interstitium producing large pools of mucus/colloid (optically "empty" spaces).mucus/colloid (optically "empty" spaces).

Margins that appear clearMargins that appear clear It is poorly differentiated. If the mucus remains inside the It is poorly differentiated. If the mucus remains inside the

tumor cell, it pushes the nucleus to the periphery- "tumor cell, it pushes the nucleus to the periphery- "signet-signet-ring cellring cell".".

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Gastric adenocarcinoma is a malignant epithelial tumor, originating from Gastric adenocarcinoma is a malignant epithelial tumor, originating from glandular epithelium of the gastric mucosa. glandular epithelium of the gastric mucosa. According to Lauren classification, gastric adenocarcinoma may be: According to Lauren classification, gastric adenocarcinoma may be: intestinal type, diffuse type and mixed typeintestinal type, diffuse type and mixed type

Whatever the histologic variant, all gastric Whatever the histologic variant, all gastric carcinomas eventually penetrate the wall to involve carcinomas eventually penetrate the wall to involve the the serosaserosa, spread to regional and more distant , spread to regional and more distant lymph nodes, lymph nodes, and metastasize widely. and metastasize widely.

For obscure reasons, the earliest lymph node For obscure reasons, the earliest lymph node metastasis may sometimes involve a metastasis may sometimes involve a supraclavicular supraclavicular lymph node (Virchow's node).lymph node (Virchow's node).

Another somewhat unusual mode of Another somewhat unusual mode of intraperitonealintraperitoneal spread in females is to both the spread in females is to both the ovaries, giving rise to the so-called ovaries, giving rise to the so-called Krukenberg Krukenberg tumortumor


Gastric cancer. A, Intestinal type demonstrating gland formation by malignant cells, which are invading the muscular wall of the stomach. (H & E.)

B, Diffuse type demonstrating individual red, mucin-containing malignant cells in the lamina propria of an intact mucosa. (Mucicarmine stain.)

Gastric CarcinomaGastric Carcinoma

Malignant

Normal Gland

Stages Stages • Early stageEarly stage limited in the mucosa and submucosa layers, no limited in the mucosa and submucosa layers, no matter with or without lymph node metastasismatter with or without lymph node metastasis Classified byClassified by the Japanese Society for Gastric the Japanese Society for Gastric CancerCancer <1cm <0.5cm<1cm <0.5cm

• Advanced stageAdvanced stage invaded over submucosainvaded over submucosa According to According to Bormann’ classificationBormann’ classification

Morphology---early stageMorphology---early stage

Morphology ---advanced stageMorphology ---advanced stage

• Gastric Gastric adenocarcinoma, adenocarcinoma, intestinal typeintestinal type, , infiltrating muscularis infiltrating muscularis propria. (H&E, ob. x10)propria. (H&E, ob. x10)

• Gastric adenocarcinoma, Gastric adenocarcinoma, intestinal typeintestinal type. (H&E, ob. . (H&E, ob. X40)X40)

Early gastric carcinoma Early gastric carcinoma is generally asymptomatic is generally asymptomatic and can be discovered only by repeated endoscopic and can be discovered only by repeated endoscopic examinations in persons at high risk.examinations in persons at high risk.

Advanced carcinoma also may be Advanced carcinoma also may be asymptomaticasymptomatic, but , but it often first comes to light because of abdominal it often first comes to light because of abdominal discomfort or weight loss.discomfort or weight loss.

Uncommonly, these neoplasms cause Uncommonly, these neoplasms cause dysphagiadysphagia when they are located in the cardia or obstructive when they are located in the cardia or obstructive symptoms when they arise in the pyloric canal.symptoms when they arise in the pyloric canal.

The only hope for cure is early detection and surgical The only hope for cure is early detection and surgical removal, because the most important prognostic removal, because the most important prognostic indicator is stage of the tumor at the time of resection.indicator is stage of the tumor at the time of resection.

Clinical Features

Clinical manifestationClinical manifestation

Signs and SymptomsSigns and SymptomsEarly Gastric CancerEarly Gastric Cancer

Asymptomatic or silent 80%Asymptomatic or silent 80%

Peptic ulcer symptoms 10%Peptic ulcer symptoms 10%

Nausea or vomiting 8%Nausea or vomiting 8%

Anorexia 8%Anorexia 8%

Early satiety 5%Early satiety 5%

Abdominal pain 2%Abdominal pain 2%

Gastrointestinal blood loss <2%Gastrointestinal blood loss <2%

Weight loss <2%Weight loss <2%

DysphagiaDysphagia <1% <1%

Signs and SymptomsSigns and Symptoms

Advanced Gastric CancerAdvanced Gastric Cancer

Weight loss 60%Weight loss 60%

Abdominal pain 50%Abdominal pain 50%

Nausea or vomiting 30%Nausea or vomiting 30%

Anorexia 30%Anorexia 30%

Dysphagia 25%Dysphagia 25%

Gastrointestinal blood loss 20%Gastrointestinal blood loss 20%

Early satiety 20%Early satiety 20%

Peptic ulcer symptoms Peptic ulcer symptoms 20%20%

Abdominal mass or fullness 5%Abdominal mass or fullness 5%

Asymptomatic or silent <5%Asymptomatic or silent <5%

Duration of symptoms

Less than 3 month 40%

3-12 months 40%

Longer than 12 month 20%

• Gastric adenocarcinoma, intestinal typeGastric adenocarcinoma, intestinal type. Tumor . Tumor cells describe irregular tubular structures, with cells describe irregular tubular structures, with stratification, multiple lumens surrounded by a stratification, multiple lumens surrounded by a reduced stroma reduced stroma ("back to back" aspect). ("back to back" aspect).

• The tumor invades the gastric wall, infiltrating the The tumor invades the gastric wall, infiltrating the muscularis mucosae, the submucosa and thence the muscularis mucosae, the submucosa and thence the muscularis propria.muscularis propria.

• Often it associates intestinal metaplasia in adjacent Often it associates intestinal metaplasia in adjacent mucosa. mucosa.

• Depending on glandular architecture, cellular Depending on glandular architecture, cellular pleomorphism and mucosecretion, adenocarcinoma pleomorphism and mucosecretion, adenocarcinoma may present 3 degrees of differentiation : well may present 3 degrees of differentiation : well (photo), moderate and poorly differentiate. (H&E, ob. (photo), moderate and poorly differentiate. (H&E, ob. x10)x10)

Spread of gastric carcinomaSpread of gastric carcinoma

Local infiltration (through wall of stomach to Local infiltration (through wall of stomach to peritoneum, pancreas etc)peritoneum, pancreas etc)

Lymphatic – local and regional lymph nodesLymphatic – local and regional lymph nodes Blood – liver, lungsBlood – liver, lungs Transcoelomic (across peritoneal cavity). Often Transcoelomic (across peritoneal cavity). Often

involves ovaries (esp. signet ring cancer) – involves ovaries (esp. signet ring cancer) – Krukenberg tumour.Krukenberg tumour.

Less common gastric neoplasmsLess common gastric neoplasms

LymphomaLymphomaGastrointestinal stromal tumour (GIST)Gastrointestinal stromal tumour (GIST)Neuroendocrine (carcinoid) tumoursNeuroendocrine (carcinoid) tumours

Gastric lymphomaGastric lymphoma

• Malignant neoplasm of Malignant neoplasm of mucosa associated mucosa associated lymphoid tissue (MALT)lymphoid tissue (MALT)

• A (usually) low grade B-A (usually) low grade B-cell (marginal cell) cell (marginal cell) lymphomalymphoma

Gastric lymphoma Gastric lymphoma (maltoma)(maltoma)

Neoplastic cells infiltrate Neoplastic cells infiltrate the epithelium the epithelium (lymphoepithelial lesions)(lymphoepithelial lesions)

Strongly associated with Strongly associated with H. pyloriH. pylori and can be and can be cured by eliminating cured by eliminating infection.infection.

Gastrointestinal stromal tumours (GIST)Gastrointestinal stromal tumours (GIST)

Mesenchymal neoplasmsMesenchymal neoplasmsDerived from interstitial cells of Cajal Derived from interstitial cells of Cajal

(pacemaker cells controlling peristalsis)(pacemaker cells controlling peristalsis)Overexpress Overexpress c-kit c-kit oncogeneoncogene

Used as diagnostic aid on tissueUsed as diagnostic aid on tissueA target for therapy with tyrosine kinase inhibitor A target for therapy with tyrosine kinase inhibitor

imatinib (also used in CML)imatinib (also used in CML)

GIST-spindle cell neoplasm of GI tractGIST-spindle cell neoplasm of GI tract

GISTGIST

• Larger tumours with high mitotic rate tend to Larger tumours with high mitotic rate tend to behave malignantlybehave malignantly

• Stomach is commonest siteStomach is commonest site

Neuroendocrine tumoursNeuroendocrine tumours

Carcinoids are tumours of resident Carcinoids are tumours of resident neuroendocrine cells in gastric glandsneuroendocrine cells in gastric glands

Usually seen in context of chronic atrophic Usually seen in context of chronic atrophic gastritis (driven by gastrin)gastritis (driven by gastrin)

Clinical behaviour variableClinical behaviour variable

INVESTIGATIONS: INVESTIGATIONS:

A.A. Upper gastero intestinal Upper gastero intestinal endoscopy endoscopy

with multiple biopsy and brushwith multiple biopsy and brush

cytologycytology

B.B. Radiology:Radiology: CT Scan of the chest and abdomenCT Scan of the chest and abdomen

USS upper abdomenUSS upper abdomen

Barium mealBarium meal

C.C. Diagnostic laparoscopyDiagnostic laparoscopy

Treatment Treatment

Surgical resection

EMR=Endoscopic mucosal resection

Adjuvant therapy

Palliative therapy

TREATMENTSTREATMENTS OFOF GASTRICGASTRIC CANCER:CANCER:TREATMENTSTREATMENTS OFOF GASTRICGASTRIC CANCER:CANCER:

SurgerySurgery (Early or Advanced (Early or Advanced Cancer)Cancer)

Distal tumours which involve the Distal tumours which involve the lower lower ½ (sub-total or partial ½ (sub-total or partial

gasterectomy).gasterectomy).

Proximal tumours which involve Proximal tumours which involve the the fundus, cardia or body fundus, cardia or body

(total (total gasterectomy).gasterectomy).

Chemotherapy for gastric Chemotherapy for gastric cancercancer

(Pre-operatve & post-(Pre-operatve & post-operative)operative)

RadiotherapyRadiotherapy

(Pre-intra & post-operatively) (Pre-intra & post-operatively)

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