Gastric carcinoma

  • Adenocarcinoma
    • Highest incidence in age > 60 years.(MCQ)
    • Adenocarcinoma comprises 95% of malignant gastric cancer. .(MCQ)
    • Male predominance.
    • Risk factors.(MCQ)
      • Familial adenomatous polyposis
      • Chronic atrophic gastritis
      • H. pylori infection (6increased risk) .(MCQ)
      • Post-partial gastrectomy (15+ years) .(MCQ)
      • Pernicious anemia
      • Diet (foods high in nitrites—preserved, smoked, cured)
      • Cigarette smoking
      • Duodenal ulcer disease may be protective against gastric cancer. .(MCQ)
    • Pathology
      • Polyploid: 25–50%, no substantial necrosis or ulceration
      • Ulcerative: 25–50%, sharp margins
      • Superficial spreading:
        • 3–10%,
        • involves mucosa and submucosa only,
        • best prognosis.(MCQ)
      • Linitis plastica:
        • 7–10%,
        • involves all layers
        • extremely poor prognosis.(MCQ)
    • Signs and symptoms
      • Early: Mostly asymptomatic.
      • Late:
        • Anorexia/weight loss, nausea, vomiting
        • dysphagia, melena, hematemesis
        • pain is constant, nonradiating, exacerbated by food. .(MCQ)
        • Anemia—from blood loss, pernicious
      • Krukenberg’s tumor.(MCQ)
        • metastasis to ovaries
      • Blumer’s shelf.(MCQ)
        • metastasis to pelvic cul-de-sac, felt on digital rectal exam
      • Virchow’s node.(MCQ)
        • metastasis to lymph node palpable in left supraclavicular fossa
      • Sister Mary Joseph’s nodule.(MCQ)
        • metastasis to the umbilical lymph nodes
    • Diagnosis
      • Upper GI endoscopy:
        • Best method, .(MCQ)
        • allows for biopsy
        • definitive >95% sensitivity and specificity
      • Upper GI series: .(MCQ)
        • With double contrast;
        • 80–96% sensitivity, 90% speci- ficity (operator dependent)
        • excellent method in skilled hands
      • Abdominal CT: .(MCQ)
        • Good for detecting distant metastases
        • also used for preop staging, but suboptimal
      • Endoscopic ultrasound:
        • Good for detecting depth of invasion
    • Staging
      • Birmingham Staging System
      • Clinico pathological system.(MCQ)
        • Does not require detailed lymph node status
        • Stage1-Disease confined to muscularis propria
        • Stage 2-Muscularis and serosal involvement
        • Stage 3-Gastric and nodal involvement
        • Stage 4 a-Residual disease
        • Stage 4 b-Metastatic disease
    • Treatment
      • Radical subtotal gastrectomy.(MCQ)
        • can be curative in early disease confined to the superficial layers of the stomach (less than one third of all patients due to typical late presentation)
      • Chemotherapy:.(MCQ)
        • Sometimes used palliatively for nonsurgical candidates
        • no role for adjuvant chemotherapy
    • Prognosis
      • Prognosis depends on stage of disease.
      • Overall 5-year survival is still only 5–15%.
  • Gastric Lymphoma.(MCQ)
    • Second most common malignant gastric cancer
    • Comprise only 5% of all gastric tumors
    • Increased× risk with HIV.(MCQ)
    • Male predominance 1.7:1.(MCQ)
    • Signs and symptoms
      • Nonspecific; include abdominal discomfort, nausea, vomiting, anorexia, weight loss, and hemorrhage.
    • Diagnosis
      • Made by endoscopic biopsy, not readily distinguishable from adenocarcinoma by simple inspection.
      • Bone marrow aspiration and gallium bone scans can diagnose metas- tases.
    • Staging (ann arbor classification) .(MCQ)
      • Stage I: Disease limited to stomach
      • Stage II: Spread to abdominal lymph nodes
      • Stage III: Spread to lymph nodes above and below the diaphragm
      • Stage IV: Disseminated lymphoma
      • MALT (low grade)— .(MCQ)
        • Treat H. pylori.
      • MALT (high grade) or non-MALT.(MCQ)
        • Radiation/chemo
        • Resection reserved for patients with bleeding or perforation
    • Prognosis
      • Poor prognostic factors include: .(MCQ)
        • Involvement of the lesser curvature of the stomach
        • Large tumor size
        • Advanced stage
    • Gastric Sarcoma
      • Equal incidence in men and women (unlike gastric adenocarcinoma or gastric lymphoma)
      • Usual age at diagnosis is 65 to 70 years
      • Most are leiomyosarcomas.
      • Spread is hematogenous treatment.
      • Surgical resection.
    • Gastrointestinal Stromal Tumor (GIST)
      •  Arises from interstitial cell of Cajal (intestinal pacemaker) (MCQ)
      • Ckit mutation/CD117+ (MCQ)
      •  Gain of function tyrosine kinase
      •  Resect if possible;
      • Imatinib mesylatefor mets; (MCQ)
      • role of Imatinib mesylate in adjuvant being currently evaluated

Clinical pearls :

  • Carney triad: (MCQ)
    • Gastric leiomyo sarcoma
    • Pulmonary chondromas
    • Extra-adrenal paraganglioma
    • Syndrome seen in women under 40
  • Adenocarcinoma of stomach(MCQ)
    •  Resect with 6 cm margins + draining lymph nodes + omentum(MCQ)
    • no obvious role for extended lymphadenectomy(MCQ)
    •  Chronic atrophic gastritis underlies most gastric cancer;
    •  other risks: adenoma > 2 cm, Type A blood, nitrosamines, pernicious anemia(MCQ)
  • Lymphoma:
    • distinguish between Tcell, NHL (nonMALT), and MALT
    • Extranodal marginal Zone BCell lymphoma (low grade Bcell lymphoma of MucosaAssociated Lymphoid Tissue, MALT):
    •  50% of patients with gastric NHL have the indolent MALT type
    •  gastric MALT is frequently associated with chronic gastritis and H.pylori infection(MCQ)
    • the standard treatment for MALT patients (who are H.pylori +)(MCQ)
    • antibiotics and followup
    • EGD 3 and 6 months later: (MCQ)
      •  if CR – done
      •  if PR -continue antibiotics before XRT (not surgery)
      • Surgery reserved for complications
    • Note: the thicker the lesion the less likely it will regress with eradication of H.pylori alone

Gastric Cancer
Gastric Cancer Video
Radation for Gastric or Stomach Cancer
D2 Gastrectomy for locally advanced gastric cancer
Surgery remains a mainstay in treatment for stomach malignancies. The key principle of oncological surgery is resection within healthy tissue with visualization of all vessels and adequate lymphnode dissection.

Endoscopy of Gastric Cancer.
An endoscopy of gastric cancer is observed
A gastric carcinoma is a malignant tumour arising from the epithelium of the stomach. Adenocarcinoma accounts for 95% of gastric malignancies, the remaining 5% being composed of lymfomas.
Although its frequency has decreased dramatically during the last few decades in the Western world, this cancer still contributes significantly to the overall mortality.
Early Gastric Cancer
Early gastric cancer (EGC) is defined as invasive gastric cancer that invades no more deeply than the submucosa, irrespective of lymph node metastasis (T1, any N). While EGC is of particular importance for patient care in Eastern Asia, its significance extends to other disciplines and patient populations:

gastric carcinoma
diffuse type — linitis plastica
total gastrectomy with roux -en y esophagus -jejunostomy
Process conducted by the surgeon Amer Abdul Hussain Alwish in disease and gastrointestinal surgery center’s Hospital coral education in the province of Babylon.
Small Gastric Cancer with Signet Ring Cells
An endoscopy with Small Gastric Cancer with Signet Ring Cells is shown

Signet ring cell carcinoma is a poorly differentiated adenocarcinoma in which the tumour cells invade singly or in small groups. Early stages of the disease can be missed easily when using regular haematoxylin and eosin staining.
Endoscopy of an Advanced Gastric Cancer
This video clip shows an upper endosocpy of advanced gastric cancer
Endoscopy of a Gastric Cancer
The prognosis for gastric cancer depends on its stage; so, detection in the early stage of disease is important, when complete and curative removal is possible. Accurate diagnosis can be facilitated by a sound understanding of the basic findings of white light endoscopy of early gastric cancer, and diagnosis can be refined further by the combined use of other imaging modalities such as image-enhanced endoscopy including chromoendoscopy and endoscopic ultrasonography.