GASTRIC CARCINOMA

Issah J. kiswagala

(M.B.B.S)

SURGICAL ANATOMY

• Fundus
• Part of the stomach which projects upwards and lies in contact with the left dome of diaphragm.
• It is usually full of gas.

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• Body
• Extends from fundus to incisura angularis.
• It has a lesser curvature and a greater curvature.

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• Pyloric antrum
• It extends from incisura till pylorus. Pylorus is thicker than the rest of the stomach.
• It has a sphincter of circular muscle fibres.
• Its canal is usually closed.

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• Greater curvature
• It lies in contact with transverse colon and gastrocolic omentum

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CARCINOMA STOMACH

• ‘It is the captain of men of death’

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EPIDEMIOLOGY�

• It is more common in Japan – 70 per 1,00,000 population.
• It is more common in males (2 times) in men compared to women.
• Rare below 40. Average age is 63 years.
• Decrease incidence in western world (Western Europe and US) – last four decades. But this decrease is confined to distal gastric cancers. Incidence of proximal gastric cancer is increasing.
• In western countries, carcinoma stomach is more common in proximal, near O—G junction.
• In Asian countries, it is still common in distal stomach.

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RISK FACTORS/AETIOLOGY

• Familial—10%. It causes hereditary diffuse gastric cancer.
• Smoking, alcohol.
• Chronic gastritis (atrophic, autoimmune), intestinal metaplasia.
• Helicobacter pylori infection—high risk (Cag A strain) 6 fold increase in incidence.
• Diet—High salt diet, food with more nitrosamines increases the risk. Smoked salmon fish increases the risk. Rich fatty food, Diet low in carbohydrate, Animal protein.

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• Fruits and vegetables rich in vitamin ‘C’ protect from carcinoma stomach.
• Chronic benign gastric ulcer.
• Pernicious anemia - causes atrophic gastritis and precipitates carcinoma of fundus of the stomach (high risk 6 times).
• Adenomatous polyps which occur in the antrum have highest risk of malignant transformation (larger polyps, i.e. more than 2 cm-10 to 20% malignant transformation).
• Lynch syndrome often called hereditary nonpolyposis colorectal cancer (HNPCC), is an inherited disorder of autosomal dominant caused by a mutation in one of four genes confers that increases the risk of many types of cancer particularly cancer of the colon and rectum, endometrium, stomach

• Li-Fraumen syndrome. (a rare disorder that greatly increases the risk of developing several types of cancer)
• Gastric dysplasia.
• Gastric mucosa of people with blood group ‘A’ is more susceptible for carcinogens—diffuse type.

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WHO CLASSIFICATION

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• WHO histological classification of gastric cancer (microscopic).

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• Adenocarcinoma 95% (commonest)
• Papillary, tubular
• Mucinous
• Signet ring
• Adenosquamous cell carcinoma
• Squamous cell carcinoma
• Undifferentiated carcinoma
• Unclassified carcinoma

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LAUREN'S CLASSIFICATION �(DIO CLASSIFICATION)

1. Intestinal type (53%)—Has got favourable prognosis. Polypoid and superficial types are intestinal varieties—Common in H. pylori induced.

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• Diffuse type (33%)—It has got poor prognosis. Common in blood group A, familial type, young people and females.

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• Others—Unclassified (14%).

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CLINICAL FEATURES

• Very often patients would have vague symptoms early satiety, flatulence, discomfort, pain in the upper abdomen.
• Early satiety is due to decreased distensibility of the stomach.
• Anaemia is due to many factors (one of the common presentations caused by poor conversion of ferrous to ferric, haematemesis as in ulcerative lesions or proliferative lesions, GI blood loss, poor intake due to early satiety and loss of appetite.

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• Clinical features can be summarized as the single word “SOLID”

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• S - Silent: Growth is silent but manifests as secondaries in the liver, ascites, Virchow's node, rectovesical deposits, peritoneal cul-de-sac deposits (Blumer's shelf), umbilical nodule (Sister Mary Joseph's nodule), left axillary nodes (Irish nodes), palpable ovarian mass (Krukenberg tumour)

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• O - Obstruction at pylorus (pyloric antrum) producing pyloric obstruction with features of vomiting with/without blood. Visible gastric peristalsis can also be present. Obstruction at cardio-oesophageal junction produces dysphagia

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• L - Lump (Swelling) in the abdomen which is hard and irregular

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• I - Insidious in onset: Anaemia, anorexia and asthenia of short duration.

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• D - Dyspepsia in a man over the age of 40: Carcinoma stomach should be ruled out. Early gastric cancer presents as dyspepsia.

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• Nonmetastatic conditions such as thrombophlebitis (Trousseau's sign) and deep venous thrombosis can occur due to change in thrombotic and haemostatic mechanisms.

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STAGING

The TNM Classification of malignant tumors is globally recognized standard for classifying the extent of spread of cancer

DIFFERENTIAL DIAGNOSIS

• Acid peptic disease; pyloric stenosis with gastric outlet obstruction.
• Gastritis.
• Pancreatic mass - carcinoma.
• Transverse colon mass – carcinoma.
• Advanced fixed stomach mass may mimic retroperitoneal or nodal mass.

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INVESTIGATIONS

• Complete blood picture: 20% of early gastric cancer patients have iron deficiency (microcytic, hypochromic) anaemia. Preoperative blood transfusion may be necessary.
• Barium meal may show intrinsic, persistent, irregular, filling defect. (barium has become almost nil with the availability of endoscopy)
• Flexible oesophagogastroduodenoscopy (OGD) (extent of the lesion, confirm the diagnosis, take multiple biopsy,)
• Ultrasound and CT scan (rule out secondaries in the liver, Can detect ascites, look for enlarged coeliac nodes, Useful in detecting metastatic disease)

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PRE-REFERRAL TREATMENT

• Complete blood picture
• Routine examination, such as fasting and postprandial sugars, ECG, renal function tests
• Parenteral feeding
• Blood Transfusion if its accessable
• Make sure the patient is stable and all baseline investigations are done
• Refer.

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TREATMENT

• Surgery is the treatment of choice for carcinoma stomach.
• Adjuvant chemotherapy has been found to be beneficial in a few patients only.
• Palliative Treatment: To palliate pain, vomiting or when there is bleeding, to improve appetite

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PROGNOSIS

• Overall prognosis is worse in carcinoma stomach. (Early gastric cancer has got better prognosis if detected early)

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FOLLOW-UP

• Follow-up visits for stomach cancer are usually scheduled:
• 3 months after the initial treatment
• Every 3–6 months for the first 2 years
• Every 6–12 months for the next 3 years
• Every year after that

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DURING A FOLLOW-UP VISIT

• You will usually ask about the side effects of treatment and how he/she is coping. You may also ask about how well he/she is eating if had surgery to remove stomach.
• You may do a physical exam, including an exam of the abdomen.
• Tests are often part of follow-up care. You may have:
• Check vitamin B12 levels to see I fthe stomach can no longer absorb vitamin B12 for the patients who had all or part of stomach removed.
• Endoscopy to check if stomach cancer has come back
• blood tests, including a complete blood count and blood chemistry tests
• imaging tests such as CT scans or x-rays.

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PREVENTIVE MEASURES

• Diet, nutrition, (avoid a diet that is high in smoked and pickled foods and salted meats and fish. But a diet high in fresh fruits and vegetables can also lower stomach cancer risk).
• body weight, and physical activity (Being overweight or obese may add to the risk of stomach cancer. On the other hand, being physically active may help lower your risk).
• Avoiding tobacco use (risk of cancers of the proximal stomach)
• Treating H pylori infection
• Aspirin use (lower the risk of stomach cancer, colon polyps and colon cancer. But can also cause serious (and even life-threatening) internal bleeding and other potential health risks in some people)
• For people at greatly increased risk (Hereditary): Early test and opt for prophylactic managements.

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