Stomach NeoplasmsProfessor Ravi KantFRCS (England), FRCS (Ireland), FRCS(Edinburgh), FRCS(Glasgow), MS, DNB, FAMS, FACS, FICS, Professor of Surgery

Stomach NeoplasmMaltomaLymphomaGISTCA stomach

Gastric Lymphoma

Most common primary GI Lymphoma .Its increasing in frequency.

Presentation: Similar to gastric carcinoma. May reveal peripheral adenopathy, abdominal mass or splenomegaly.

Diagnosis: 1.EGD 2.contrast GI x-ray. 3.CT guided fine needle biopsy.Treatment : Gastric Lymphoma Rx is Surgery(Other organs- preferred Rx of Lymphoma is Chemotherapy or Radiotherapy)

MaltomaMucosa associated lymphoid tumour

MALTOMAAetiology= H PyloriRx = Rx of H Pylori= Triple drugs

What are GIST??Gastrointestinal Stromal Tumors are uncommon mesenchymal tumors that arise in the wall of the gastrointestinal tract It is believed to originate from an intestinal pacemaker cell called the interstitial cell of Cajal.

Cajal cell

An intestinal pacemaker cell, has been proposed the cellular origin of GISTs. It has characteristics of both smooth muscle and neural differentiation on ultrastructural examination

KITrole of the KIT and platelet-derived growth factor receptor (PDGFR) tyrosine kinase receptors KIT receptor tyrosine kinase (KIT RTK)

KITapproximately 5% of GIST cells show not activation and aberrant signaling of the KIT receptor, but rather mutational activation of a structurally related kinase, PDGFR- (PDGFRA). 90% rate of mutations seen in a more recent series searching for potential mutations in each of exons 11, 9, 13, and 17

CD117CD34Actin & Desmin S-100GIST++--Desmoid tumor-+--True leiomyosarcoma--+-Schwanoma---+

DiagnosisCT is the common mode of diagnosisFDG PET is mandatory PET CT scan is idealMR

GIST & chemoresistance P-glycoprotein [the product of the multidrug resistance-1 (MDR-1) gene] MDR protein

DistributionStomach 50-60%Small bowel 20-30%Large bowel 10%Esophagus 5%Else where in abdomen 5%

Symptoms Abdominal pain Dysphagia Gastrointestinal bleeding Symptoms of bowel obstruction Small tumors may be asymptomatic

CytologicallySpindle cell GISTsEpithelioid cell GISTsAlthough GISTs can differentiate along either or both cell types, some show NO significant differentiation at all

DiagnosisMUST BE DONE IMMUNOCHEMICALLY

The CD34 antigen (70-78%)The CD117 antigen (72-94%)

Malignant Versus Benign

SizeMitotic countVery Low risk

predictors of survivalMale sex, Tumor size > 5cmIncomplete resectionsignificant on multivariate analysis

TreatmentSurgical excision is primary treatment option but recurrence rates are highResistant to standard chemotherapy regimens due to over-expression of efflux pumpsRadiation therapy limited by large tumor sizes and sensitivity of adjacent bowel

IMATINIBSince activation of Kit played a crucial role in the pathogenesis of GIST, inhibition of Kit would be therapeutic

IMATINIBOrally bioactive tyrosine kinase inhibitorShown to be effective against GIST tumors in two trials in the US and Europe reported in 2001 & 2002

Gastrointestinal Stromal Tumor GIST

Previously leiomyoma & leiomyosarcoma.

Usually are discovered incidentally on endoscopy or barium mealThe endoscopic biopsies may be uninformative as the overlying mucosa is usually normalSmall tumorswedge resectionLarger onesgastrectomy

*

*

GISTCase history-submucosalCajal CellGene KIT PGDRFDiagnosisCTPETRxSurgeryChemoresistanceImatininbSumanitibPrognosisPredictor factors

*

GASTRIC CARCINOMA

GASTRIC NEOPLASM

Epithelial Mesenchymal1.PrimaryAdenocarcinomaGastrointestinal stromal tumors GISTLymphoma 2. Secondary: invasion from adjacent tumors.BenignMalignant

Gastric Carcinoma55 year old Japanese male who is living in Japan & working in industry.DEFINITIONMalignant lesion of the stomach.Epidemiology & Risk FactorsCan occur at any ageBut Peak incidenceIs 50-70 years old.It is more aggressiveIn younger ages.Japan has the world highest Rate of gastric cancer.Studies have confirmed that incidence decline inJapanese immigrant to America.

dust ingestion from a variety of industrial processes may be a risk.

Twice more commonIn male than in femaleIncidence of Gastric Carcinoma:Japan 70 in100,000/yearEurope 40 in 100,000/yearUK 15 in 100,000/yearUSA 10 in 100,000/yearIt is decreasing worldwide.

Gastric Carcinoma:Risk FactorsPredisposing :

1. Pernicious anaemia & atrophic gastritis (achlorhydra)2. Previous gastric resection3. Chronic peptic ulcer (give rise to 1%)4. Smoking.5. Alcohol. Environmental:

1.H.pylori infection Sero(+)patients have 6-9 folds risk2.low socioeconomic Status3. nationality (JAPAN)4. Diet (prevention)

Genetic:

1.Blood group A2.HNPCC: Hereditary non-polyposis colon cancer.

Clinical PresentationMost patients present with advanced stage.. why?They are often asymptomatic in early stages.

Common clinical Presentation:The patient complained of loss of appetite that was followed by weight loss of 10Kg in 4 weeks. He had notice epigastric discomfort & postprandial fullness. He presented to the ER complaining of vomiting of large quantities of undigested food & epigastric distension.

Dyspepsia epigastric painBloating early satiety nausea & vomiting* dysphagia* anorexia weight loss upper GI bleeding (hematemesis, melena, iron deficiency anemia)

signs-Anemia.-Wt. loss ( cachexia)-Epigastric mass, Hepatomegaly, Ascitis -Jaundice.-Blumers shelf -Virchow's node-Sister Mary Joseph node -Krukenberg tumor-Irish node

Pathology DIO Classification

Lauren Classification:

1. Intestinal Gastric ca. It arises in areas of intestinal metaplasia to form polypoid tumors or ulcers.

2. Diffuse Gastric ca. It infiltrates deeply in the stomach without forming obvious mass lesions but spreads widely in the gastric wall Linitis Plastica & it has much more worse prognosis

3. Mixed Morphology.

Morphology Polypoid Ulcerative Superficial spreading Linitis plastica

Gastric cancer can be divided into:

Early: Limited to mucosa & submucosa with or without LN (T1, any N) >> curable with 5 years survival rate in 90%.

Advanced: It involves the Muscularis. It has 4 types( Bormanns classification). Type III & IV are incurable.

Staging of gastric cancer

Spread of Gastric CancerDirect SpreadBlood-borne metastasisLymphatic spreadTransperitonealspreadTumor penetrates themuscularis, serosa & Adjacent organs(Pancreas,colon &liver)What is important here isVirchows node (Trosiers sign)Usually with extensive Disease where liver 1stInvolved then lung &BoneThis is commonAnywhere in peritoneal cavity(Ascitis)Krukenberg tumor (ovaries)Sister Joseph nodule(umbilicus)

Complications Peritoneal and pleural effusion

Obstruction of gastric outlet or small bowel

Bleeding

Intrahepatic jaundice by hepatomegaly

Differential Diagnosis1.Gastric ulcer

2.Other gastric neoplasms3.Gastritis4.Gastric Polyp5.Crohns disease.From history,Cancer is not relieved by antacidsNot periodicNot relieved by eating or vomiting.

INVESTIGATIONSFull blood count IDA- LFT,RFTAmylase & lipase.Serum tumor markers (CA 72-4,CEA,CA19-9) not specificStool examination for occult bloodCXR ,Bone scan.

Specific:UGI endoscopy with biopsy Double contrast studyCT, MRI & USLaparoscopry

EGD esophagogastroduodenoscopy Diagnostic accuracy is 98% if up to 7 biopsies is taken.

Double Contrast barium upper GI x-ray Diagnostic accuracy 90% WHY?

Diagnostic study of Choice1.Early superficial gastric mucosal lesion can be missed.2. cant differentiate b/w benign ulcer & Ulcerating adenocarcinoma.

X-ray showing Gastric ulcer With symmetrical radiating Mucosal folds.By histology, no evidence of Malignancies was observed.X-ray showing Extensive carcinoma involving the cardia & FundusPyloric stenosis

CT,MRI & US:

Laparoscopy:

Help in assessment of wall thickness, metastases (peritoneum ,liver & LN)Detection of peritoneal metastases

THE GOLD STANDARD It allows taking biopsies Safe (in experienced hands)UGI ENDOSCOPY

UGI ENDOSCOPY,contd.

You may see an ulcer (25%), polypoid mass (25%), superficial spreading (10%),or infiltrative (Linitis plastica)-difficult to be detected-Accuracy 50-95% it depends on gross appearance, size, location & no. of biopsies

IF YOU SEE ULCER ASK UR SELFBENIGN OR MALIGNANT?

ManagementSurgery

Chemotherapy NO PROVEN BENEFITRadiotherapy

TreatmentInitial treatment:1.Improve nutrition if needed by parenteral or enteral feeding.2.Correct fluid &electrolyte & anemia if they are present.Preoperative CarePreoperative Staging is important because we dont want to subject the patient to radical surgery that cant help him.

PRE-OPERATIVE CARECareful preoperative stagingScreen for any nutritional deficiencies & consider nutritional supportSymptomatic control Blood transfusion in symptomatic anemiaHydrationProphylactic antibioticsABO & cross matchAsk about current medications & allergiesCessation of smoking

BASIC SURGICAL PRINCIPLES3 TYPES: TOTAL,SUBTOTAL,PALLIATIVEANTRAL DISEASESUBTOTAL GASTRECTOMYMIDBODY & PROXIMAL TOTAL GASTRECTOMY

TOTAL (RADICAL) GASTRECTOMY

Remove the stomach +distal part of esophagus+ proximal part of duodenum + greater & lesser omentum + LN Oesophagojejunostomy with roux-en-y .

SUBTOTAL GASTRECTOMYSimilar to total one except that the PROXIMAL PART of the stomach is preservedFollowed by reconstruction & creating anastomosis ( by gastrojejunostomy, Billroth II )

PALLIATIVE SURGERYFor pts with advanced (inoperable) disease & suffering significant symptoms e.g. obstruction, bleeding.Palliative gastrectomy not necessarily to be radical, remove resectable masses & reconstruct (anastomosis/intubation/stenting/recanalisation)

POSTOPERATIVE ORDERSAdmit to PACUDetailed nutritional advise (small frequent meals)

Post-Operative Complications1.Leakage from duodenal stump.

2.Secondary hemorrhage.

3.Nutritional deficiency in long term.

2.Chemotherapy: Responds well, but there is no effect on survival.Marsden RegimenEpirubicin, cisplatin &5-flurouracil (3 wks)6 cyclesResponse rate : 40% .3. Radiotherapy: Postperative-radiotherpy: may decrease the recurrence.

Preventive measuresBy dietConvincing:vegetable & fruits.Probable: Vit. C &EPossible Carotenoids, whole grain cereals and green tea. Smoking cessation Cessation of alcohol intake

PROGNOSTIC FEATURES2 important factors influencing survival in resectable gastric cancer: depth of cancer invasion presence or absence of regional LN involvement5yrs survival rate: 10% in USA 50% in Japan

E-medicine web siteThe Washington Manual of SurgeryBailey & Loves short practice of surgeryClinical surgery ( A. Cuschieri).

**Linitis plastica:*Billrothantrectomy with gastrojejunostomyRoux en y jejunojejunostomy forming a Y shaped figure of small bowel, the free end then can be anastomosed with another hollow structure