GASTRIC TUMOURS

 Anatomy of the stomach

 Aetiology of Gastric cancer
 Types of Gastric cancer
 Pathology of Gastric Cancer
 Evaluation of Gastric Cancer
 Treatment of Gastric Cancer
ANATOMY:

 The stomach J-shaped. The stomach

has two surfaces (the anterior &
posterior), two curvatures (the greater &
lesser), two orifices (the cardia &
pylorus). It has fundus, body and pyloric
antrum.
 Anatomy
• Stomach has five layers:
– Mucosa
• Epithelium, lamina propria, and muscularis
mucosae*
– Submucosa
– Smooth muscle layer
– Subserosa
– Serosa
AETIOLOGY:

 Gastric cancer is the second most

common fatal cancer in the world with
high frequency in Japan.

 The disease presents most commonly in

the 5th and 6th decades of life and affect
males twice as often as females.
Contn…
 The cause of the disease multistep process
but several predisposing factors attributed
to cause the disease :

a. Environment e. Atrophic gastritis

b. Diet f. Chronic gastric ulcer
c. Heredity g. Adenomatous polyps
d. Achlorhydria h. Blood group A
i. H. Pyloric colonisation
TYPES OF GASTRIC CANCER:

A. Benign Tumours

B. Malignant Tumours
TYPES OF GASTRIC CANCER:

A. Benign Tumours

B. Malignant Tumours
THE BENIGN TUMORS:

 Although benign tumors can

occur in the stomach most
gastric tumours are malignant.
 The benign groups includes:-
1. Non-neoplastic gastric polyps
2. Adenomas
3. Neoplastic gastric polyps
4. Smooth muscles tumours benign
(Leiomyomas)
5. Polyposis Syndrome (eg:- Polyposis coli,
Juvenile polyps and P.J. Syndrome)
6. Other benign tumours are fibromas,
neurofibromas, aberrat pancreas and
angiomas.
PATHOLOGY OF GASTRIC (MALIGNANT)
TUMOURS:

 The gastric cancer may arise in

the antrum (50%), the gastric
body (30%), the fundus or
oesophago-gastric juntion (20%).
 Types of Malignant Tumours:

a. Adenocarcinoma

b. Leiomyosarcoma

c. Lymphomas

d. Carcinoid Tumours
 The macroscopic forms of gastric cancers are
classified by (Bormann classification) into:-
1. Polypoid or Proliferative
2. Ulcerating
3. Ulcerating/Infiltrating
4. Diffuse Infiltrating (Linnitus-
Plastica)
Microscopically the tumours commonly
adenocarcinoma with range of
differentiation. The most useful to
clinician and epidemiologist is Lauren
Histological Classification:

a. Intestinal gastric cancer

b. Diffuse gastric cancer
 Gastric Carcinoma
• Diffuse • Intestinal

• M:F 1:1 • M:F 2:1

• Onset Middle Age • Onset Middle Age
• 5 yr surv overall <10% • 5 yr surv overall 20%
• Aetiology • Aetiology
– Diet – Unknown
– H. pylori – Blood group A association
– H. pylori
 Early Gastric Cancer: Defined as
cancer which is confined to the
mucosa and submucosa regard-
less of lymph nodes status.

 Advanced Gastric Cancer:

Defined as tumor that has involved
the muscularis propria of the
stomach wall.
SPREAD OF GASTRIC CANCER:
 The diffuse type spreads rapidly
through the submucosal and serosal
lymphatic and penetrates the gastric
wall at early stage, the intestinal variety
remains localized for a while and has less
tendency to disseminate.
The spread by:
1. Direct (loco regional)
2. Lymphatic
3. Blood (Haematogenous)
4. Transcoelomic
Clinical Manifestation:
1. Weight loss due to anorexia and early satiety is
the most common symptoms
2. Abdominal pain (not severe) common
3. Nausea / vomiting
4. Chronic occult blood loss is common;
GIT bleeding (5%)
5. Dysphagia (cardia involvement)
Clinical Manifestation:
6. Paraneoplastic syndromes ( Trousseau’s
syndrome – thrombophlebitis; acanthosis
nigricans – hyperpigmentation of axilla and
groin; peripheral neuropathy)
7. Signs of distant metastasis:
a. Hepatomegally / ascites
b. Krukenbergs tumor
c. Blummers shelf (drop metastasis)
d. Virchow’s node
e. Sister Joseph node (pathognomonic of advances
dse)
 SUMMARY:
 Often asymptomatic until late stage.
 Marked weight loss
 Anorexia
 Feeling of abdominal fullness or discomfort
 Epigastric mass
 Iron Deficiency Anaemia
 Left supraclavicular mass (Troisier’s Sign)
 Obstructive Jaundice (Secondary in porta
hepatitis)
 Pelvic mass (Krukenberg)
EVALUATION OF GASTRIC CANCER:
 History
 Clinical Examination
 Investigations

 The clinical features of gastric cancer

may arise from local disease, its
complications or its metastases.
INVESTIGATIONS:
A. Upper gastero intestinal endoscopy
with multiple biopsy and brush
cytology
B. Radiology:
 CT Scan of the chest and abdomen
 USS upper abdomen
 Barium meal

C. Diagnostic laparoscopy
Diagnosis:

1. Endoscopy (Biopsy / Ultrasound)

• GOLD STANDARD
• Best pre-operative staging
• Needle aspiration of LN w/ ultrasound guidance
• Can even give preop neoadjuvant tx
2. CT scan (intravenous and oral contrast):
• For pre-operative staging
3. Whole body Positron Emission Tomography
scanning (PET):
• Tumor cell preferentially accumulate positron-
emitting 18F fluorodeoxyglucose.
 Laboratory
• Assists in determining optimal therapy.
• CBC identifies anemia, with may be caused
by bleeding, liver dysfunction, or poor
nutrition.
• 30% have anemia.
• Electrolyte panels and LFTs are also
essential to better characterize patients
clinical state.
 Investigations for patients with
gastric cancer
• Endoscopy & biopsy

• Performance status
• Physiological assessment
– Cardio-pulmonary function

• CT chest & abdomen

• EUS (endoscopic ultrasound)
• Laparoscopy
 CT scanning
• Technique
– Spiral CT of chest and
abdomen
 Laparoscopy
• Inspect peritoneal surfaces, liver surface.
• Identification of advanced disease avoids
non-therapeutic laparotomy in 25%.
• Patients with small volume metastases in
peritoneum or liver have a life expectancy
of 3-9 months, thus rarely benefit from
palliative resection.
 Screening of Gastric Cancer
• Patients at risk for gastric CA should
undergo yearly endoscopy and biopsy:
1. Familial adenomatous polyposis
2. Hereditary nonpolyposis colorectal cancer
3. Gastric adenomas
4. Menetrier’s disease
5. Intestinal metaplasia or dysplasia
6. Remote gastrectomy or gastrojejunostomy
 TREATMENTS OF GASTRIC CANCER:

 Surgery (Early or Advanced Cancer)

 Distal tumours which involve the lower
½ (sub-total or partial gasterectomy).

 Proximal tumours which involve the

fundus, cardia or body (total
gasterectomy).
 Treatment of gastric cancer
• Endoscopic treatment
– EMR (endoscopic mucosal resection)
– ablation
• Surgery
• Multimodal treatment
– Neo-adjuvant
– Adjuvant
• Palliative treatment
 Complications
• Mortality 1-2%
• Anastamotic leak, bleeding, ileus, transit
failure, cholecystitis, pancreatitis,
pulmonary infections, and
thromboembolism.
• Late complications include dumping
syndrome, vitamin B-12 deficiency, reflux
esophagitis, osteoporosis.
OTHER GASTRIC TUMOURS:
 Gastric Lymphomas:
 Primary lymphomas of the stomach of the
non Hodgkin’s type (NHL).
 The symptoms are similar to those of
gastric cancer (adenocarcinoma).
 The diagnosis is made principally from
endoscopic examination with biopsy and
cytology.
 CT Scanning is important in staging the
disease.
 Treatment:
- Well-localized disease should be treated
with resection (surgery) followed by
radiotherapy or chemotherapy.
- Extensive disease by adjuvant chemo-
therapy & radiotherapy than surgery.
 Leiomyosarcoma:
 Arise in the stomach representing 1% of
gastric tumors.
 They may be sessile or pedanculated
projecting into the gastric lumen or
extragastrical or both (dumb-bell
tumour).
 Presentation due to blood loss anaemia or
epigastric mass or vague dyspepsia.
 Malignancy is suggested by the size more
than 5cm and confirmed by noting
increased mitosis on histology.
 Stromal tumours
• GIST (Gastro-Intestinal Stromal Tumour)
– Presentation
• Incidental
• Bleeding
– Pathology
• Blend sheets of spindle cells
• Previously mistaken for leiomyomata
• Origin cell – interstitial cell of Cahal
• C-kit +ve
• Actin -ve
 Stromal tumours
• Prognostic factors
– Size (>4cm)
– Resection margins

– Mitoses
– Vacuoles on EUS
 Stromal tumours
• Surgical Treatment
– Excision with clear margins
– No lymphadenectomy required
• Non –surgical treatment
– Glivec (imatinib)
– Recurrence / inoperable
– ? Neoadjuvant / adjuvant
 Gastric Carcinoid Tumour:
 Are very rare. There is established
association between atrophic gastritis &
carcinoid & pernicious anemia.

 Gastric carcinoids are best treated by

local resection. If very small by
endoscopic resection.