Gastric tumorsGastric tumors

Dr. Mohammad Shaikhani.Dr. Mohammad Shaikhani.

Assistant professorAssistant professor

Sulaimanyah college of Medicine.Sulaimanyah college of Medicine.

BENIGN TUMORSBENIGN TUMORS:: Leiomyomas:Leiomyomas: smooth muscle tumors, equal in men /women, typically located in the smooth muscle tumors, equal in men /women, typically located in the

middle &distal stomach. middle &distal stomach. Can grow into the lumen with secondary ulceration & bleeding. or expand to the Can grow into the lumen with secondary ulceration & bleeding. or expand to the

serosa with extrinsic compression. serosa with extrinsic compression. Endoscopy show a mass with overlying intact or ulcerated mucosaEndoscopy show a mass with overlying intact or ulcerated mucosa Ba: usually smooth with an intramural filling defect, with or without central Ba: usually smooth with an intramural filling defect, with or without central

ulceration. ulceration. Can be difficult to distinguish from their malignant counterparts radiographically Can be difficult to distinguish from their malignant counterparts radiographically

or endoscopically;so tissue diagnosis needed. or endoscopically;so tissue diagnosis needed. If symptomatic should be removed.If symptomatic should be removed. Other benign tumors: lipoma, neurofibroma, lymphangioma, ganglioneuroma, Other benign tumors: lipoma, neurofibroma, lymphangioma, ganglioneuroma,

hamartoma, the latter associated with Peutz-Jeghers syndrome or juvenile polyposis hamartoma, the latter associated with Peutz-Jeghers syndrome or juvenile polyposis (restricted to the stomach).(restricted to the stomach).

BENIGN TUMORSBENIGN TUMORS::

BENIGN TUMORSBENIGN TUMORS:: ADENOMASADENOMAS Gastric adenomas & hyperplastic polyps are unusual but may be Gastric adenomas & hyperplastic polyps are unusual but may be

found in middle-aged & elderly patients. found in middle-aged & elderly patients. Polyps sessile or pedunculated found in 50% with familial Polyps sessile or pedunculated found in 50% with familial

adenomatosis polyposis or Gardner’s syndrome.adenomatosis polyposis or Gardner’s syndrome. Generally asymptomatic, some may have dyspepsia, nausea, or Generally asymptomatic, some may have dyspepsia, nausea, or

bleeding. bleeding. Are smooth /regular on upper GI series, but the diagnosis must be Are smooth /regular on upper GI series, but the diagnosis must be

confirmed by upper endoscopy with biopsy. confirmed by upper endoscopy with biopsy. Pedunculated polyps > 2 cm or with associated symptoms should Pedunculated polyps > 2 cm or with associated symptoms should

be removed by endoscopic snare cautery polypectomy& large be removed by endoscopic snare cautery polypectomy& large sessile gastric adenomatous polyps may merit segmental surgical sessile gastric adenomatous polyps may merit segmental surgical resection.resection.

If polyps progress to severe dysplasia or cancer, the treatment is If polyps progress to severe dysplasia or cancer, the treatment is the same as for gastric adenocarcinomathe same as for gastric adenocarcinoma

STOMACH ADENOCARCINOMA STOMACH ADENOCARCINOMA Great geographic variation, strongly indicating that Great geographic variation, strongly indicating that

environmental factors influence its pathogenesis. environmental factors influence its pathogenesis. It is extremely common among males in certain regions, as It is extremely common among males in certain regions, as

tropical South America, some parts of the Caribbean, Eastern tropical South America, some parts of the Caribbean, Eastern Europe. Europe.

Regardless of gender, it remains the most common malignancy in Regardless of gender, it remains the most common malignancy in Japan &China. Japan &China.

Gastric adenocarcinoma of distal stomach declined &that of Gastric adenocarcinoma of distal stomach declined &that of proximal gastric & gastroesophageal adenocarcinomas steadily proximal gastric & gastroesophageal adenocarcinomas steadily increasing in US.increasing in US.

ADENOCARCINOMA : RFsADENOCARCINOMA : RFs Environmental,Genetic Environmental,Genetic H.pyloriH.pylori infection infection Genotoxic agents as Genotoxic agents as NN-nitroso compounds may play a -nitroso compounds may play a

role ,formed in the human stomach by nitrosation of ingested role ,formed in the human stomach by nitrosation of ingested nitrates, which are common constituents of the diet.nitrates, which are common constituents of the diet.

Atrophic gastritis with or without intestinal metaplasia. Atrophic gastritis with or without intestinal metaplasia. Pernicious anemia is associated with *7 increase. Pernicious anemia is associated with *7 increase. The achlorhydria associated with gastritis related to The achlorhydria associated with gastritis related to H. pyloriH. pylori, ,

pernicious anemia, vagotomy or other causes favors the growth of pernicious anemia, vagotomy or other causes favors the growth of bacteria capable of converting nitrates to nitrites. bacteria capable of converting nitrates to nitrites.

Subtotal gastrectomy for benign disorders increase risk of gastric Subtotal gastrectomy for benign disorders increase risk of gastric ca.ca.

Menetrirr’s disease: hypertrophic gastritis.Menetrirr’s disease: hypertrophic gastritis. Benign gastric ulcers do not predispose to gastric cancer. Benign gastric ulcers do not predispose to gastric cancer.

Clinical features:Clinical features: In early stages, gastric cancer may often be asymptomatic or produce only In early stages, gastric cancer may often be asymptomatic or produce only

nonspecific symptoms, making early diagnosis difficult.nonspecific symptoms, making early diagnosis difficult. Later symptoms include bloating, dysphagia, epigastric pain, or early Later symptoms include bloating, dysphagia, epigastric pain, or early

satiety. satiety. Early satiety or vomiting may suggest partial gastric outlet Early satiety or vomiting may suggest partial gastric outlet

obstruction&gastric dysmotility cause vomiting in nonobstructive cases. obstruction&gastric dysmotility cause vomiting in nonobstructive cases. Epigastric pain, as that with peptic ulcer, occurs in 1/4; but in the Epigastric pain, as that with peptic ulcer, occurs in 1/4; but in the

majority,the pain is not relieved by food or antacids.majority,the pain is not relieved by food or antacids. Pain that radiates to the back may indicate that the tumor has penetrated Pain that radiates to the back may indicate that the tumor has penetrated

into the pancreas. into the pancreas. When dysphagia,it suggests a more proximal gastric tumor at the GEJ or in When dysphagia,it suggests a more proximal gastric tumor at the GEJ or in

the fundus.the fundus.

Clinical features:Clinical features: Bleeding, which can result in anemia, produces the symptoms of Bleeding, which can result in anemia, produces the symptoms of

weakness, fatigue, malaise as well as more serious weakness, fatigue, malaise as well as more serious cardiovascular& cerebral consequences. cardiovascular& cerebral consequences.

Perforation related to gastric cancer is unusual. Perforation related to gastric cancer is unusual. Gastric cancer metastatic to the liver can lead to right upper Gastric cancer metastatic to the liver can lead to right upper

quadrant pain, jaundice &/or fever. quadrant pain, jaundice &/or fever. Lung metastases can cause cough, hiccups, hemoptysis.Lung metastases can cause cough, hiccups, hemoptysis. Peritoneal carcinomatosis can lead to malignant ascites Peritoneal carcinomatosis can lead to malignant ascites

unresponsive to diuretics. unresponsive to diuretics. Gastric cancer can also metastasize to bone.Gastric cancer can also metastasize to bone.

Clinical features: PEClinical features: PE In the earliest stages may be unremarkable. In the earliest stages may be unremarkable. At later stages, cachectic, epigastric mass may be palpated.At later stages, cachectic, epigastric mass may be palpated. If the tumor has metastasized to the liver, hepatomegaly with If the tumor has metastasized to the liver, hepatomegaly with

jaundice / ascites may be present. jaundice / ascites may be present. Portal or splenic vein invasion can cause splenomegaly. Portal or splenic vein invasion can cause splenomegaly. Lymph node involvement in the left supraclavicular area is Lymph node involvement in the left supraclavicular area is

termed Virchow’s node&periumbilical nodal involvement is termed Virchow’s node&periumbilical nodal involvement is called Sister Mary Joseph’s node. called Sister Mary Joseph’s node.

The fecal occult blood test may be positive.The fecal occult blood test may be positive. Paraneoplastic syndromes may precede or occur concurrently Paraneoplastic syndromes may precede or occur concurrently Trousseau’s syndrome: recurrent migratory superficial Trousseau’s syndrome: recurrent migratory superficial

thrombophlebitis indicating a possible hypercoagulable state; thrombophlebitis indicating a possible hypercoagulable state; Acanthosis nigricans:arises in flexor areas with skin lesions that Acanthosis nigricans:arises in flexor areas with skin lesions that

are raised &hyperpigmented.are raised &hyperpigmented. Neuromyopathy with involvement of the sensory / motor Neuromyopathy with involvement of the sensory / motor

pathways.pathways. CNS involvement with altered mental status /ataxia.CNS involvement with altered mental status /ataxia.

Diagnosis: LabDiagnosis: Lab IDA. IDA. Predisposing pernicious anemia can progress to megaloblastic Predisposing pernicious anemia can progress to megaloblastic

anemia. anemia. Microangiopathic hemolytic anemia has been reported. Microangiopathic hemolytic anemia has been reported. Abnormalities in liver tests generally indicate metastatic disease. Abnormalities in liver tests generally indicate metastatic disease. Hypoalbuminemia is a marker of malnourishment.Hypoalbuminemia is a marker of malnourishment. Protein-losing enteropathy is rare but can be seen in Ménétrier’s Protein-losing enteropathy is rare but can be seen in Ménétrier’s

disease, another predisposing condition. disease, another predisposing condition. Serologic test results,as carcinoembryonic antigen & CA 72.4, Serologic test results,as carcinoembryonic antigen & CA 72.4,

may be abnormal. may be abnormal. Although these tests are not recommended for original diagnosis, Although these tests are not recommended for original diagnosis,

they may be useful for monitoring disease after surgery.they may be useful for monitoring disease after surgery.

Diagnosis: endoscopy & imagingsDiagnosis: endoscopy & imagings Endoscopy with biopsy&cytology: 95 -99% Efficacy.Endoscopy with biopsy&cytology: 95 -99% Efficacy. Appear as small mucosal ulcerations, polyp, or a mass Appear as small mucosal ulcerations, polyp, or a mass In some, gastric ulceration may first be noted in an UGI barium In some, gastric ulceration may first be noted in an UGI barium

contrast. contrast. Ba: A benign gastric ulcer is suggested by a smooth, regular base, Ba: A benign gastric ulcer is suggested by a smooth, regular base,

whereas a malignant ulcer is manifested by a surrounding mass, whereas a malignant ulcer is manifested by a surrounding mass, irregular folds& an irregular base. irregular folds& an irregular base.

Upper endoscopy with biopsy & cytology is mandatory whenever Upper endoscopy with biopsy & cytology is mandatory whenever a gastric ulcer is found in the radiologic study, even if the ulcer a gastric ulcer is found in the radiologic study, even if the ulcer has benign characteristics.has benign characteristics.

DiagnosisDiagnosis

Diagnosis: imagingsDiagnosis: imagings Staging of gastric cancer, enhanced by EUS. Staging of gastric cancer, enhanced by EUS. The extent of tumor, including wall invasion & local lymph node The extent of tumor, including wall invasion & local lymph node

involvement, can be assessed by EUS &it is complementary to CT. involvement, can be assessed by EUS &it is complementary to CT. EUS help guide aspiration biopsies of lymph nodes to determine EUS help guide aspiration biopsies of lymph nodes to determine

their malignant features, if any. their malignant features, if any. CT scans of the chest / abdomen should be performed to CT scans of the chest / abdomen should be performed to

document lymphadenopathy& extragastric organ (especially document lymphadenopathy& extragastric organ (especially lung/liver) involvement.lung/liver) involvement.

In some centers, staging of gastric cancer needs bone scans In some centers, staging of gastric cancer needs bone scans because of the possibility of metastasize to bone.because of the possibility of metastasize to bone.

Treatment: surgeryTreatment: surgery The only chance for cure is surgical resection, possible in 25-30%. The only chance for cure is surgical resection, possible in 25-30%. If confined to the distal stomach, subtotal gastrectomy with If confined to the distal stomach, subtotal gastrectomy with

resection of lymph nodes in the porta hepatis & pancreatic head. resection of lymph nodes in the porta hepatis & pancreatic head. In tumors of the proximal stomach total gastrectomy to obtain an In tumors of the proximal stomach total gastrectomy to obtain an

adequate margin & to remove lymph nodes+ distal adequate margin & to remove lymph nodes+ distal pancreatectomy &splenectomy, but with higher mortality/ pancreatectomy &splenectomy, but with higher mortality/ morbidity. morbidity.

Limited gastric resection is necessary for patients with excessive Limited gastric resection is necessary for patients with excessive bleeding or obstruction& If cancer recurs in the gastric remnant. bleeding or obstruction& If cancer recurs in the gastric remnant.

Treatment: chemoradiotherapyTreatment: chemoradiotherapy Gastric cancer is one of the few GI cancers responsive to Gastric cancer is one of the few GI cancers responsive to

chemotherapy. chemotherapy. Single-agent treatment with 5-fluorouracil, doxorubicin, Single-agent treatment with 5-fluorouracil, doxorubicin,

mitomycin C, or cisplatin provides partial response rates 20- mitomycin C, or cisplatin provides partial response rates 20- 30%. 30%.

When used in combination, yield partial response 35-50%. When used in combination, yield partial response 35-50%. Radiation therapy alone is ineffective & employed only for Radiation therapy alone is ineffective & employed only for

palliative purposes in the setting of bleeding, obstruction, or pain. palliative purposes in the setting of bleeding, obstruction, or pain. The combination of chemotherapy (fluorouracil + leucovorin) The combination of chemotherapy (fluorouracil + leucovorin)

with radiation improve median survival from 27 months to 36 with radiation improve median survival from 27 months to 36 months compared with surgery alone in patients with months compared with surgery alone in patients with adenocarcinoma of the stomach or gastroesophageal junction.adenocarcinoma of the stomach or gastroesophageal junction.

Treatment: othersTreatment: others

Gene therapy& immune-based therapy are currently only Gene therapy& immune-based therapy are currently only investigational.investigational.

Treatment: Treatment: Supportive:Supportive: Nutrition (jejunal enteral feedings or total parenteral nutrition), Nutrition (jejunal enteral feedings or total parenteral nutrition), Correction of metabolic abnormalities that arise from vomiting or Correction of metabolic abnormalities that arise from vomiting or

diarrheadiarrhea Treatment of infection from aspiration or spontaneous bacterial Treatment of infection from aspiration or spontaneous bacterial

peritonitis. peritonitis. To maintain lumen patency, endoscopic laser treatment or To maintain lumen patency, endoscopic laser treatment or

stenting for palliation.stenting for palliation.

PrognosisPrognosis 1/3 who undergo a curative resection are alive after 5 years. 1/3 who undergo a curative resection are alive after 5 years. The overall 5-year survival < 10%. The overall 5-year survival < 10%. Prognostic factors include: Prognostic factors include: 1. Anatomic location & nodal status: Distal gastric cancers 1. Anatomic location & nodal status: Distal gastric cancers

without LN involvement have a better prognosis than proximal without LN involvement have a better prognosis than proximal gastric cancers with or without LN involvement. gastric cancers with or without LN involvement.

2. Depth of penetration& tumor cell DNA aneuploidy: Linitis 2. Depth of penetration& tumor cell DNA aneuploidy: Linitis plastica& infiltrating lesions have a much worse prognosis than plastica& infiltrating lesions have a much worse prognosis than polypoid disease or exophytic masses. polypoid disease or exophytic masses.

Early gastric cancer:Early gastric cancer: In early gastric cancer mostly Japanese confined to the mucosa In early gastric cancer mostly Japanese confined to the mucosa

&submucosa, surgical resection may be curative &definitely &submucosa, surgical resection may be curative &definitely improves the 5-year survival rate to > 50%. improves the 5-year survival rate to > 50%.

When early gastric cancer is confined to the mucosa, endoscopic When early gastric cancer is confined to the mucosa, endoscopic mucosal resection (EMR) may be an alternative. mucosal resection (EMR) may be an alternative.

Gastric lymphomaGastric lymphoma:: 5% of all malignant gastric tumors.5% of all malignant gastric tumors. Increasing in incidence. Increasing in incidence. The majority are non-Hodgkin’s lymphomas & the stomach is the most common The majority are non-Hodgkin’s lymphomas & the stomach is the most common

extranodal site for non-Hodgkin’s lymphomas. extranodal site for non-Hodgkin’s lymphomas. Generally younger than those with gastric adenocarcinoma,also male predominance. Generally younger than those with gastric adenocarcinoma,also male predominance. Commonly present with symptoms & signs similar to adenoca. Commonly present with symptoms & signs similar to adenoca. Lymphoma in the stomach can be a primary tumor or can be due to disseminated Lymphoma in the stomach can be a primary tumor or can be due to disseminated

lymphoma.lymphoma. B-cell lymphomas of the stomach are most commonly large cell with a high-grade B-cell lymphomas of the stomach are most commonly large cell with a high-grade

type. type. Low-grade variants are noted in the setting of chronic gastritis & termed mucosa-Low-grade variants are noted in the setting of chronic gastritis & termed mucosa-

associated lymphoid tissue (MALT) lymphomas. strongly associated with associated lymphoid tissue (MALT) lymphomas. strongly associated with H. pyloriH. pylori infection.infection.

Gastric lymphomaGastric lymphoma:: Ba: usually ulcers or exophytic masses; a diffusely infiltrating Ba: usually ulcers or exophytic masses; a diffusely infiltrating

lymphoma is more suggestive of secondary lymphoma. lymphoma is more suggestive of secondary lymphoma. Barium usually show multiple nodules& ulcers for a primary Barium usually show multiple nodules& ulcers for a primary

gastric lymphoma&typically have the appearance of linitis gastric lymphoma&typically have the appearance of linitis plastica with secondary lymphoma. plastica with secondary lymphoma.

UGI endoscopy with biopsy/cytology are required for diagnosis UGI endoscopy with biopsy/cytology are required for diagnosis with accuracy of 90%. with accuracy of 90%.

Conventional histopathology& immunoperoxidase staining for Conventional histopathology& immunoperoxidase staining for lymphocyte markers is helpful in diagnosis. lymphocyte markers is helpful in diagnosis.

Proper staging of gastric lymphoma involves EUS, chest& Proper staging of gastric lymphoma involves EUS, chest& abdominal CT scans& bone marrow biopsy.abdominal CT scans& bone marrow biopsy.

Gastric lymphomaGastric lymphoma:: Treatment of gastric diffuse large B-cell lymphoma is best Treatment of gastric diffuse large B-cell lymphoma is best

pursued with combination chemotherapy with or without pursued with combination chemotherapy with or without radiotherapy with 5-year survival rates of 40-60%. radiotherapy with 5-year survival rates of 40-60%.

For MALT lesions, eradication of For MALT lesions, eradication of H. pyloriH. pylori with antibiotics with antibiotics induces regression of the tumor, but longer term follow-up is induces regression of the tumor, but longer term follow-up is needed.needed.

Radiotherapy can be curative for localized MALT lymphomas.Radiotherapy can be curative for localized MALT lymphomas.