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PROF.DR.V.SHRUTHI KAMAL

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INCIDENCE GLOBAL STATISTICS 640600 MEN 349000 WOMEN 50% adavanced carcinoma CA CANCER J.CLIN 2011

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Distal cancer Increase in proximal cancers Incidence remains high in Japan Their cure rates better due to screening/ survellance/early detection

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Age Average age of onset 55 yrs

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Etiology Diffuse cancer Proximal & hereditary Intestinal type Distal cancers younger Endemic/ inflammatory changes with Helicobacter pylori infection

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DIET Linked to High ingestion of Redmeat/cabbage/spices/fish/smoked Salt preserved/high carohydrates Low ingestion of fruits vegetables Fat /protein/vitamins A,C,E

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Gastric Cancer Dietary/Lifestyle Factors Carl-McGrath S, et al. Cancer Therapy (2007).

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Helicobacter pylori infection Increased risk HP organism found in 89% intestinal type/32% with diffuse type Trials in eradicating HP infection

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Heredity & Race African/Asian/Hispanic American >risk Whites< risk

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Anemia pernicious anemia 3to18 times > risk Achlorhydria Atrophic gastritis

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Previous Gastric resection Gastric stump ca > 15 to 20 yrs Alakaline bile/dysplasia of gastric ca/ elevated gastrin levels > carry poor prognosis

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Mucosal dysplasia Grade I to III High grade dysplasia >marker for future gas.ca Intestinal metaplasia/ replacement of Glandular epithelium> intestinal type

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Gastric Cancer Correa Sequence- pathophysiology Vogelgram of CRC http://www.hopkinscoloncancercenter.org Increasing risk Normal Chronic gastritis Mucosal atrophy Intestinal metaplasi a Intestinal-type carcinoma Dysplasia Potentially reversible Not HGD Hartgrink HH, et al. Lancet (2009).

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Gastric polyps FAP ( Familial adenomatous polyposis) Have > incidence of gas.ca/advised endoscopy/ survellence Hyper plastic>do not have malig.potential

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Chronic gastritis Atrophic gastritis( autoimmune) Hypertrophic gastritis Menetriers

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Other risk factors > 50 yrs Blood group A Lower socio economic status Alcohol Smoking Obesity

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Histology Adeno ca >95% Leiomyo sarcoma Lymphomas Squamous ca >5% Carcinoid

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Other risk factors contd E cadheringene mutation HNPCC LIFraumen EB virus

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Pathology Gross types> cauliflower ulcerative Leather botttle (linitis plastica)

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Laurens Intestinal type(53%) Good prognosis HP infection Diffuse type(33%) Bld group A,Familial, signet ring,poor differentiation, younger bad prognosis

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Japanese classification Early gastric > mucosa+ submucosa+ or - nodes 1 protruded cure rate >95% 2 superdicial 3 Excavated

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Advanced gastric ca Muscularis+serosa + or nodes Borrmans classification I single polypoid II ulcerated ca + clear margin III,,,,,, + with out clear margin IV diffuse & V unclassified

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MINGS classification Expanding Infiltrative

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WHO Histological( Microscopic) Adeno ca>papillary,tubular mucinous,signet Adenosuamous Squamous undifferentited

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Siewert classifiaction Proximal gas.ca TypeI Ca of GE ( Barrets) TypeII With in 2 cms Squamo columnar junc TypeIII Subcardial

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Location of cancers Distal >40% Proximal>35% Body>25%

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Spread Local Ulcerative> gsatric wall> serosa schirrous>submucosa/muscularis Lymphatic Virchows node ( left supraclavicular ) Left axillary (Irish node) Blood spread>liver 40%Lung 40% Sclerotic bone mets/carcinomatous meningitis

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contd Peritoneum 10% seedling of peritoneal surfaces Umbilicus/falciform(sis Mary joseph nodule) Krukenberg>mets to ovary Blumer shelf ( rectal shelf in men)

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Paraneoplastic syndrome Polymyosistis Dementia Venous thrombosis Ectopic cushing Leser Trelat sign( seborheic keratosis) Acanthosis

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Diagnosis Anorexia/early satiety/dyspepsia Dyspagia/weakness/ Abdominal pain>60% Weight loss>50% Nausea vomiting>40% Palpable mass>30% Haemetemis/ malena>25%

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Investigations CBC/LFT/Chest x-ray EGD( esophagogastroduodenoscopy) USG/EUS(endo ultrasound) CT Diagnostic lap

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Staging TNM Tx cant be assessed T0 No eveidence of tumour Tis in situ T1 lamina propria or submucosa T2 a muscularis propria T2 binvades subserosa T3 invades serosa T4 adjacent structure

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Gastric Cancer Staging Systems TNM: most important clinical prognostic factor http://www.hopkins- gi.org http://www.medscape.com/viewarticle/543068_3

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Nodes Nx cant be assessed No no nodes N1 1-6 nodes N2 7-15 nodes N3 > 15 nodes

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Meatastasis Mx Mets cant be assessed Mo No mets M1 distant mets

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Management Surgery > Curative 1 Endoscopic mucosal resection 2 Subtotal gastrectomy distal 2cm & proximal 5 cm clearance(Billroth II) 3 Total gastrectomy (Roux en y)

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Inoperable tumours Multiple mets liver Extensive invovolment adjacent organs SMV/SMA Carcinomatosis peritonei

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Resection R0 resection > No residual disease R1 >microscopic residual disease R2> Macroscopic residual disease R3> unresectable

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Nodal stations First tier nodes 1-6 nodes Second tier nodes 7-11 nodes Third tier nodes 12-18 nodes D1 dissection nodes are N0 (3-6) D2 dissection(N1) 1-11 removed D3dissection(N2)paraaortic hepatodudenal D4 1-18 stations

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Surgery -contd Palliation Palliative resection Palliative by pass Anterior Gastrojejunostomy/feeding jejunostomy Laser ablation/ stenting Pain relief

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Chemotherapy Adjuvant chemo therapy 5 FU225mg/m2/days 1-5/1-21 Epirubicin50mg/m2 day1 Cisplatin 60mg/m2/day1

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Chemo for advanced ca ECF epirubicin/5 FU/Doxorubicin EOX epirubicin/0xaliplatin/capecitabine DCF Docetaxel/cisplatin/5FU

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Radio therapy-Role Helpful in palliation for unrsectable tumors(4000cgy 4wks) IORT (tumour bed)

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Prognosis Early 5 yr survival 70- 90% Advanced ca less than 20% Recurrence with in 3 yrs

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Gastric lymphoma Primary- elderly/NHL-B cell type Mucosal associated lymphoid tissue (MALTOMA)/H.pylori Loss of appetite/pain abdomen/wt loss Mass abdomen Associated SLE/HIV/Ch gastritis etc

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complications Obstruction Perforation Bleeding metastasis

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treatment Treat HP infection Surgery for obstruction Chemo same as NHL

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GIST-gastroinestinal stromal tumor Non epithelial /equal sex incidence 50-70 yrs Arises from interstitial cell of cajal Treat surgery Chemo sunitinib imatinib

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THANK YOU