Professional Documents
Culture Documents
Pankaj Tejasvi
Dept. of Surgery
MGMMC & MYH Indore
GE Junction –
Z – line /
Squamocolumnar jn.
Rugal folds
Fat pad
Collar of Helvetius /
Loop of Willis
DIVISIONS OF STOMACH –
Cardia
Fundus
Body / Corpus
Pyloric antrum
Pyloric canal
PYLORUS
Left gastric
nodes
Celiac group
Thoracic duct
LGE
nodes
RGE nodes
LAYERS OF STOMACH
SubserosalCT
EPIDEMIOLOGY of Gastric Cancer
East Asia and South America M:F=2:1
Most common cancer in JAPAN 7th decade
JAPAN
THE MAGNITUDE OF PROBLEM
Male : Lung > Prostate > Colorectal > Stomach
4th most common cancer in men
Female : Breast > Cervix > Colorectal > Lung > Stomach
5th most common cancer in women
Medical
* Prior gastric surgery (bile gastritis)
Others
* Male gender
* Pernicious anaemia (achlorhydria)
* Proto oncogene overexpression – c-met , k-sam , c-erbB2
* Inactivation of tumor suppressor gene – p53 and p16
H.Pylori & Gastric carcinoma
• RESERVOIRS: human, primates, cats,
sheeps.
• Gram-negative spiral bacillus.
• Grows at pH: 4.5-9
• M/C site of colonisation - antrum
Virulence :
cagA gene
Mutation : p53
Over-expression : COX-2, cyclin D2
Decrease expression : p27
Microsatellite instability
PPI and Gastric cancer
• PPI blocks H+-K+ pump
• Hypergastrinemia
* Adenocarcinoma – 90%
* Lymphoma – 5%
* GIST – Gastrointestinal stromal tumors – 2%
* SCC – Squamous cell carcinoma - <1%
* Carcinoid tumors - <1%
* Adenocanthoma - <1%
* Signet ring cell Carcinoma
Signet ring cell carcinoma (SRCC)
A ring that kills….
• Contrary to others gastric cancer, the incidence of SRCC of the stomach is rising.
• SRCC tumors grow in characteristic sheets, which makes diagnosis using standard
imaging techniques, like CT and PET scans, less effective.
• Causes:
- inherited - mutations in CDH1 gene (cell-cell adhesion glycoprotein E-cadherin)
Once these cells lose E-cadherin, their motility increases
- APC gene mutation
• Prognosis
Early SRCC – better or atleast similar to than of non-SRCC
Advanced SRCC – poor than non-SRCC and lower chemosensitivity and peritoneal
carcinomatosis is the most frequent metastatic site.
PATHOLOGIC CLASSIFICATION
Ulcerative Type 2
advanced disease
at the time of diagnosis
*Epigastric pain
*Nausea and vomitting
*Early satiety
*Weight loss
* GI bleeding
- Anemia 40%
- frank hematemesis 15%
- Melaena
* Palpable mass
– Linitis Plastica
* Krukenberg’s tumor
* Blummer’s shelf
*2011 consensus guidelines
Imaging EUS
CECT
2 major staging systems for gastric carcinoma
TX – Primary tumor
can’t be assessed
Mucosa
T0 – No evidence of
primary tumor T1a
Submucosa
Tis- Carcinoma in situ
T1b
Muscularis
propria
T3 – gastro-
Subserosal
colic/hepatic lig., CT
greater or lesser
omentum Serosa
RE GIONAL LYMPH NODES (N)
Based on number of LN involved and not the location
In 1997, nodal classification changed from using the location of the
involved lymph nodes to the number of lymph nodes
pN1, 1–6 nodes
pN2, 7–15 nodes
pN3, >15 nodes
-Requires a minimum of 15 nodes in the resection specimen
-Avrg no. of nodes evaluated - 10, only 30% of pts have at least 15
nodes evaluated
Because of inadequate nodal evaluation
In the 7th edition of the AJCC classification, a minimum of 7
nodes are required.
GE junction tumors
or
tumors in the cardia <5cm from GE junction extending
into GE junction
* No. 4sa LN along the greater curvature – 4sa (short gastric vessels)
- 4sb (left gastroepiploic vessels)
- 4d (right gastroepiploic vessels)
* No. 5 Suprapyloric LN
* No. 6 Infrapyloric LN
* No. 7 LN along the left gastric artery
* No. 8 LN along the common hepatic artery - 8a(anterior group)
- 8p(posterior group)
* No. 9 LN along the celiac artery
* No. 10 LN at the splenic hilum
* No. 11 LN along the splenic artery – 11p proximal splenic
- 11d distal splenic
* No. 12 LN in the hepatoduodenal ligament – 12a (along the hepatic artery)
– 12b (along the bile duct)
– 12p (behind the portal vain)
* No. 13 LN on the posterior surface of the pancreatic head
* No. 14 LN along the superior mesenteric vessels – 14v superior mesenteric vein
- 14a superior mesenteric artery
* No. 15 LN along the middle colic vessels
Right
paracardial
left gastric
artery
CELIAC
common hepatic
lesser
curvature
Suprapyloric left
gastroepiploic
Infrapyloric
right
gastroepiploic
Hepatoduodenal ligament Proximal & distal
-Hepatic artery splenic
-Portal vein
-Bile duct
Splenic
hilum
Posterior of
pancreatic
head
15
middle colic
artery and Transverse mesocolon
vein
20
16a1 Esophageal hiatus
aortic hiatus
16a2
Celiac trunk
16b2
Inferior mesentric
artery
* T staging -
The gastric wall is visualized as 5 concentric bands:
Mucosa - Echogenic
Muscularis mucosa - Hypoechoic gastric tumor -
Submucosa - Echogenic hypoechoic mass
Muscularis propria - Hypoechoic
Serosa - Echogenic
* Inferior to CT in N staging
Implications
* In resectable pts. for staging
* In unresectable pts. – determination of benefits of combined chemo-
radiation (radiation may not be appropriate in metastatic disease)
Jaffer A et al. http://www.nccn.org, v.1.2006
The depth of tumor invasion is not accurately assessed with CT, and the
investigation of choice for this indication is EUS.
Unlike CT and MRI, EUS can depict individual layers of the gastric wall, with
a rotating high-frequency probe
SURGICAL THERAPY – the only prospective of cure
Objective : Complete resection of gastric tumor with a wide (≥6cm) margin
what is R status ?
…Hermanek, 1994
Total
Endoscopic gastrectomy
sub-
mucosal
resection
Hemi- Subtotal
gastrectomy gastrectomy
A Japanese study
N = 5000
• small tumors, regardless of ulcer status, and
• nonulcerated tumors, regardless of size,
did not have associated lymph node disease.
patients with submucosal invasion less than 500 μm behaved similarly to
patients who had completely intramucosal
tumors.
Distal gastrectomy
Hemigastrectomy
Subtotal gastrectomy
Subtotal gastrectomy
Total gastrectomy
Proximal 1/3rd tumor :
D1
Perigastric nodes (station 1-6)
Conservative node dissection
D2
D1 + left gastric, Common hepatic,celiac & splenic L.N.(7-11)
Extended node dissection
D3
D2 + Hepato-duodenal ligament, retropancreatic & mesenteric root (12-16)
Super-extended lymphadenectomy
D4
D3 + para-aortic and para colic LN dissection
Extent of nodal dissection D1 v/s D2
most controversial area in gastric cancer management
Japanese literature
Increased survival in patients undergoing a D2 dissection, with no increased or
minimal increase in morbidity.
One criticism of the Western data is that although randomized, the D2 group did not
differentiate between patients who had a splenectomy and those who did not.
Subsequent subgroup analysis of the D2 without splenectomy group has shown
results similar to the Japanese studies, with increased survival and no significant
increase in morbidity.
Resectable or not ?
Involvement of other organ per se does not imply incurability, provided that it
can be removed ….Bailey and love’s short practice of surgery 26th ed.
Detachment of greater omentum from anterior layer of mesocolon is dissected Dissect upto inferior border of
colon from mesocolonic vessels pancreas and divide Rt GE vessels
Randomised controlled study of 503 pts. With stage II or higher gastric cancer that
compared perioperative chemotherapy with surgery alone.
5-yr survival, rate of local recurrence & distant metastasis were improved in CT
group
longer overall survival than with CEF and decreased incidence of thromboembolic
phenomenon by substituting oxaliplatin for cisplatin
Intraperitoneal Chemotherapy (IPC)
Recurrence following curative resection is likely due to peritoneal
carcinomatosis.
Radiotherapy is limited, due to its position near vital organs like kidney spinal cord,
pancreas, liver & bowel.
Stomach itself is highly sensitive, tends to bleed and ulcerate with EBRT.
Chen & Song 1994, China randomized stage 3 & 4 patients for surgery with IORT
Vs surgery alone claims ↑ in SR only in stage 3.
Sindelar & Tepper et al in 1993 , NCI (National Cancer institute) claims no survival
benefit with IORT, but improvement in local recurrence (44% Vs 92%, p < 0.001).
Stomach divided at greater curvature for 6-8 cm by knife (site of future Staple line inverted with
anastamosis) and then completely divided with GIA stapler suture
Bilroth II
Retrocolic Bilroth II
Anticolic Bilroth II
Standard technique for a two-layer, hand-sewn gastrojejunal anastomosis
Anterior
row of
interrupted
3-0 silk
Lembert
sutures
After Subtotal gastrectomy Roux-en-Y gastrojejunostomy
• Partial gastrectomy
• Total gastrectomy
59% felt improved their QOL ….Monson JR et al. Cancer 1991;68:1863-8
• Esophago-gastrectomy
• Jejunostomy - for nutritional supplementation
• acute refractory hemorrhage - Endoscopic techniques (laser argon ablation,
epinephrine injection) and arterial embolization
• GOO – endoscopic dilation and stent placement (short term), CT, bypass with
gastrojejunostomy
Palliative Chemotherapy