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Gastric Cancer

Professor Dr.
Bedii Berat APAYDIN
Epidemiology of Gastric Cancer
 Gastric ca. is the 13th most common & the 10th
most deadly cancer in US
 Japan, Chile, China, Iceland & Finland have a high
rate of incidence & death from this malignancy
 Its true incidence has declined by more than
40 % in the last 30 years in the US
 Its world wide frequency has albeit diminished
less dramatically
 Decline in mortality rate in Japan in the past
years has been the result of mass screening
 Location of the cancers has shifted from the distal
to the proximal portion of the stomac
 Is 2 times more common in men than in women
 Its incidence & mortality increase with age (>50)
Risk Factors for Gastric Cancer
 Heredity
 Age
 Gender
 Diet
 Social habits
 Occupation
 Predisposing conditions
 H.pylori
 Hypogammaglobulinemia
Risk Factors for Gastric Cancer
 The fact that the incidence in Japan, Chili
Iceland & Finland is 5-6 times as great as
those in other parts of the world, support
racial differences
 Certain families have demonstrated
multiple occurences of Gastric cancer:
Napoleon Bonaparte
 4 % of patients with gastric cancer have a
family history of gastric cancer
 Patients with gastric cancer have
frequently blood group A
Risk Factors for Gastric Cancer
 Foods high in sodium such as pickled
vegetables, salted fishes & meat
 Smoked foods
 High fat
 Items containing nitrite & nitrate
 Elevated zinc level in the water

 Gastric cancer is inversely associated with

consumption of fresh vegetable, citrous
fruits, vitamine C & whole milk
 Refrigeration has contributed to the decline
of Gastric Cancer
Risk Factors for Gastric Cancer
Social Habits

Cigarette smoking
is associated with an increased
risk for Gastric Cancer
Risk Factors for Gastric Cancer
Social & Occupational Factors
 Lower socioeconomic class
 Coal mining
 Timber processing
 Rubber production
 Fishermen
 Ceramic workers
 Textile workers
 Painters
 Asbesto exposure
have been associated with gastric ca.
Risk Factors for Gastric Cancer
Predisposing Conditions
 Chronic atrophic gastritis & intestinal
 Helicobacter pylori infection
 Gastric polyps
 Previous gastrectomy
 Pernicious anemia
 Hypertrophic gastropathy (Menetrier
have been associated with Gastric ca
Microscopic Pathology
 With only the rare exceptions of
carcinoids & squamous carcinomas,
gastric cancers are all adenocancer
 The WHO’s histologic classification
recognizes 4 patterns of adenocancer:
- papillar - mucinous
- tubular - signet ring cell
 The most widely used histopathologic
classification is described by Lauren
Lauren’s Classification of Gastric ca.
Intestinal type: Diffuse type:
 Cells of this type forme  Is composed of
glands resembling colonic
glands dispersed cells which
are not organized in
 Manifested by polipoid glandular pattern
mass or ulceration  It infiltrates stomach
 Occurs usually in wall without forming
geographic areas where mass & produces linitis
gastric ca incidence is plastica
high: worldwide  It is endemic
distrubition is epidemic
 Associated with atrophic  It is less associated
gastritis,intestinal with dietary factors
metaplasia & with diet  It is found in young & in
induced dysplastic women
changes  Has a greater tendency
 Occurs more often in men for peritoneal spreading
& in patients over age 60
 Metastasizes to the liver
Early Gastric Cancer
Gastric ca. confined to mucosa or submucosa
regardless of lymph node involvement
 EGC ranges from 8-25 % in USA &
35-50 % all of gastric ca in Japan
 70 % of EGC are well differentiated & 30 %
are poorly differentiated & lymph node
invasion is less than 5 %
 5 year survival is 99 % when cancer is
confined to the mucosa, 90 % when cancer
is confined to the submucosa & survival
drops to 70 % when lymph node
involvement is present
 EGC is divided to several types & subtypes
Advanced Gastric Cancer
 Gross morphology of advanced gastric ca.
(tumor extending beyond the submucosa)
is classified by BORMANN

 Bormann classification includes 4 distinct gross


 (%13) Type 1 polypoid

 (%25) Type 2 ulcerating with sharply defined margins
 (%36) Type 3 combined ulcerating & infiltrating
without clear cut margins
 (%26) Type 4 infiltrating
(%11) 4a : superficial spreading
(%15) 4b: linitis plastica
Symptoms of Gastric Cancer
 Diagnosis is not made until there is an extensive
involvement of the gastric wall & adjacent viscera
 Initial symptoms are vague postprandial heaviness &
epigastric discomfort not different from other dyspeptic
 Anorexia -especially for beef products & smoking- with
weight loss (6 kg) are the most common signs
 At the beginning, patients complaint from epigastric pain
which mimic peptic ulcer & responds transiently to medical
therapy, persistent pain is a late complaint
 Constipation frequently results from restricted foods
 Anemia findings (fatigue & weakness) & occult blood in the
stool are common whereas massive bleeding occurs in
less than 5 % of the patients
 Nausea & vomiting occur when distal lesions obstruct
pylorus, dysphagia occurs when cancer arises from cardia
Signs of Gastric Cancer
 Anemia findings
 Palpable abdominal mass is common: 50 %
 Abdominal tenderness is a rare finding
 Hepatomegaly suggests metastatic spread
 Peritoneal seeding may cause massive
ascites or Krukenberg’s tumor (involvement
of ovaries) or Blummer’s shelf (involvement
of Douglas)
 A palpable lymph node in the left
supraclavicular fossa (Wirchow’s node) & a
metastatic deposit to the umblicus (Sister
Joseph’s nodule) are sings of advanced
Laboratory Studies
 A microcytic anemia secondary to
chronic GI bleeding or macrocytic anemia
secondary to preexisting pernicious
anemia can be found
 Abnormal liver function tests suggest
liver metastasis
 CEA, CA19-9, α feto protein levels are
commonly elevated
 Studies of gastric acid secretion often
reveal achlorhydria or hypochlorhydria
 Serum gastrin level is elevated secondary
to achlorhydria
Radiologic Studies
 Single contrast barium study of the upper GI
tract is the first diagnostic study to evaluate
symptoms.This study detects more than 80% of
gastric ca., but it frequently misses early ca.
 Findings indicating gastric ca. are as follows:
 A mass lesion in the gastric lumen
 An obtructing lesion of the antrum and cardia
 An ulcerated mass resembling a bening ulcer
 Enlarged gastric folds
 Nondistendible stomach
 Early gastric ca. can be diagnosed by double-
contrast barium study
Endoscopic Evaluation
 Upper GI endoscopy enables the direct
visualisation,photograpic documentation
& biopsy of gastric lesions
 Visual diagnosis is accurate in 90% of
patients with gastric ca. but biopsies
must be done for histologic confirmation
 A minimum of 6 biopsy samples should
be obtained
 In infiltrative type of gastric ca. diagnosis
was made by biopsy in only 50% of
Preoperative Staging
 Once the diagnosis of gastric ca. has been
established, the extent of disease & its
resectability should be evaluated

 CT or MRI scans should be obtained to evaluate

hepatic metastasis, extansion of tm into
contiguous organs (pancreas, transverse

 Endoscopic intraluminal US provides accurate

information about the depth of penetration of tm

 Laparoscopy can be used to detect small

intraperitoneal & liver metastasis not seen on CT
Spread of Gastric Cancer
 Intramural spread
 Direct invasion
 Metastasis by way of lymphatic
 Metastasis by way of blood
 Implantation onto peritoneal
Treatment of Gastric Cancer
 Surgical therapy is the only curative treatment
 85% of patients are operable
 In 50% of patients, lesions are amenable to
 Of the resectable lesions, half are potentially
 The surgical objective is to remove the tumor,
an adjacent uninvolved margin of stomach,
the regional lymph nodes & if necessary
portions of involved adjacent organs
 Japanese surgeons recommend more agressive
lymphadenectomy as a matter of routine in the
resection of ca
For 1/3 distal stomach tumors
Resection would entail distal gastrectomy
(proximal margin should be a minimum of
6 cm from the gross tumor), with en bloc
removal of omentum, a 3-4 cm cuff of
duodenum & regional lymph nodes
(N1+N2 LN), LN12, LN13, LN16
For 1/3 middle stomach tumors &
multifocal tumors &
linitis plastica
• Total gastrectomy
• Splenectomy (if required)
• Omentectomy
• N1+N2 lymphadenectomy
(LN1-12 complete)
For 1/3 proximal stomach
• Proximal gastrectomy
• Distal esophagectomy (10 cm)
• Pancreas preserved Splenectomy 10)
• LN 1-10
• LN16
Palliative Surgical Therapy

Palliative resection is recommended if

• the stomach is movable &
• life expectancy is more than 2
• Gastrojejunostomy can be done
when resection is not feasible