Gastric tumors

Approximately 90%-95% of gastric tumors are malignant, and of the malignancies, 95% are
adenocarcinomas. Other histologic types include squamous cell, carcinoid, gastrointestinal
stromal tumor (GIST), and lymphoma.
Gastric adenocarcinoma
The incidence of gastric
adenocarcinoma has been
decreasing for many years and is
now stabilized. Gastric
adenocarcinoma is the tenth most
common cancer, with an estimated
annual incidence of 22,000 cases and
13,000 deaths. The trend is
increasing toward lesions more
proximally located in the stomach.
Risk factors for gastric cancer
include:
a. Age >70 years
b. Diet high in salt, smoked foods, low protein, low vitamins A and C
c. H. pylori infection
d. Previous gastric resection
e. Chronic gastritis and pernicious anemia
f. Blood group A
g. Radiation exposure
h. Tobacco use
i. Male gender
j. Low socioeconomic status .
k. Adenomatous polyps
 Symptoms
include epigastric pain, anorexia, fatigue,
vomiting, and weight loss. Proximal
tumors can present with dysphagia,
while more distal tumors may present as
gastric outlet obstruction. Symptoms
tend to occur late in the course of the
disease. Physical signs can include
palpable supraclavicular (Virchow's) or
periumbilical (Sister Mary Joseph's)
lymph nodes.
Diagnosis is suggested on UGI
radiographs and is confirmed by upper
endoscopy with biopsy.
Preoperative evaluation may include computed
tomography (CT) scan to look for local
extension, ascites, and distant metastases.
Endoscopic ultrasound has been shown to be
useful in determining the depth of penetration
and in detecting nodal metastases. Staging
laparoscopy may detect small peritoneal
metastases and is required before most
neoadjuvant protocols.
Involvement beyond the stomach may include
direct spread to adjacent organs (e.g., spleen,
diaphragm, omentum, colon); "drop
metastases" to the ovary (Krukenberg's tumor)
or the pelvis (Blumer's shelf tumor); or distant
disease (e.g., to liver, lung).
Classification.
Gastric carcinoma is classified according to its gross characteristics.
a. Intestinal type is a well-differentiated, glandular tumor found most
commonly in the distal stomach.
b. b. Diffuse type is a poorly differentiated, small cell infiltrating tumor
found most commonly in the proximal stomach.
 Surgical treatment
depends on nodal disease and distant metastases.
a. Potentially curable lesions
(I) Potentially curable lesions are treated with subtotal or total gastrectomy, depending
on tumor location.
(II) Wide margins (>6 cm) on the stomach are necessary because extensive submucosal
tumor spread can occur. Lesions of the fundus and cardia may require resection of
the spleen, pancreas, or transverse colon to completely remove the cancer.
The role of lymphadenectomy is controversial, but for favorable lesions, there is some
advantage to removing the local draining nodes. Removal of the omentum and its nodes
is included. Radical lymphadenectomy that includes distant nodal basins has not been
shown to improve survival and may increase morbidity. It is recommended that a least
15 regional lymph nodes be sampled to ensure adequate staging of the tumor.
Palliative resections are indicated in the
presence of obstructing or bleeding
gastric cancers. Treatment may include
resection, bypass alone, or either one in
conjunction with endoscopic or
radiotherapeutic techniques.
Adjuvant chemotherapy (5-
fluorouracil/leucovorin and radiation
therapy) after potentially curative
resection improves median survival and is
the current standard of care. Neoadjuvant
chemoradiation is being studied in several
clinical trials but remains unproven at this
time. Unresectable tumors may show
some response to chemotherapy. The
addition of radiation therapy may improve
results and can control bleeding
symptoms.
Prognosis
depends largely on the depth of invasion of the gastric wall,
involvement of regional nodes, and presence of distant metastases but
still remains poor. Overall 5-year survival after the diagnosis of gastric
cancer is 10%-20%. Tumors not penetrating the serosa and not
involving regional nodes are associated with a 5-year survival rate of
approximately 70%. This number decreases dramatically if the tumor is
through the serosa or into regional nodes. Recurrence rates after
gastric resection are high, ranging from 40%-80%. Potentially curative
surgical resection does offer a better 5-year prognosis; however, only
40% of patients have potentially curable disease at the time of
diagnosis.
 Gastric lymphoma
The stomach is the most common site of primary intestinal lymphoma;
however, gastric lymphoma is relatively uncommon, accounting for only
15% of all gastric malignancies and only 2% of lymphomas.
Symptoms are usually vague, namely abdominal pain, early satiety, and
fatigue. Rarely ever do patients present with constitutional symptoms (i.e.
"B" dassification of lymphoma). Patients at risk for developing lymphomas
are those who are immunocompromised or are harboring an H. pylori
infection.
Diagnosis consists of endoscopy with biopsy and endoscopic ultrasound
for staging. As with all lymphomas, assessment of distant disease should
include bone marrow biopsy; CT of chest, abdomen, and pelvis; as well as
an upper airway exam. Testing for H. pylori should also be performed.
Treatment consists of a multimodality regimen,
with the role of gastric resection remaining highly
controversial.
Medical treatment combining chemotherapy and
radiation is now the most accepted first line therapy
for treating gastric lymphoma. Some variants of
lymphoma may also be treated effectively by the
eradication of H. pylori infection alone.
Surgical treatment is now used mostly for the
complications of bleeding and perforation that arise
from locally advanced disease. The treatment
involves the removal of all gross disease via partial
gastrectomy.

Prognosis is good, with a 5-year survival greater

than 95% when disease is localized to the stomach
and 75% when local lymph nodes are involved.
Gastric sarcomas
arise from the mesenchymal cells of the gastric wall and constitute 3% of all gastric
cancers. Gastrointestinal stromal tumors (GIST) are the most common and are found
predominately in the stomach.
1. Gastrointestinal stromal tumors (GIST) arise from mesenchymal cells of the GI
tract, usually the pacemaker cell of Cajal.
2. Histologic diagnosis is confirmed by immunohistochemical staining for CD 117, a
cell surface antigen.
3. Presentation varies from incidental asymptomatic endoscopy or CT findings to
symptomatic large tumors causing obstruction, pain, bleeding, or metastases.
4. Treatment is complete surgical removal. Clinical behavior and malignant potential
are based on several factors, including mitotic count >5 per 50 high-power fields; size
>5 cm; and cellular atypia, necrosis, or local invasion. Tumor recurrence or
unresectable disease can be treated by imatinib mesylate (Gieevec), which inhibits
the c-KIT gene-associated tyrosine kinase receptor responsible for tumor growth.
Overall 5-year survival is 50%.
 Gastric polyps
are usually found incidentally. They often can be
excised via endoscopy. I. Hyperplastic polyps are
the most common and arise most often in the
setting of chronic atrophic gastritis. These
polyps are non-neoplastic, and treatment
consists of polypectomy.
2. Adenomatous polyps are associated with a
20% risk of malignancy, especially in those
greater than 1.5 cm. Treatment consists of
endoscopic polypectomy. Surgery is required for
evidence of invasion on polypectomy specimen,
for sessile lesions > 2 cm, and polyps with
symptoms of bleeding or pain.
Ectopic pancreas occurs during
development and is rare. The
majority of cases are found in the
stomach, duodenum, and jejunum.
The most common presenting
symptoms are abdominal pain,
nausea and vomiting, and bleeding.
Surgical excision is the
recommended treatment.
 DUODENAL TUMORS
• Malignant tumors are usually adenocarcinomas. Treatment of
resectable lesions is pancreaticoduodenectomy (Whipple's procedure).
Other tumors include carcinoids, GISTs, gastrinomas, and parcomas.
• Benign tumors include
• lipomas, benign GISTs,
• hamartomas, and adenomas.
• Surgical resection is the
• treatment of choice.
POSTGASTRECTOMY SYNDROMES

These symptom complexes can be

disabling.
• Alkaline reflux gastritis is the most
common problem after a gastrectomy,
occurring in about 25% of all patients.
• Symptoms are postprandial epigastric
pain, nausea, vomiting, and weight loss.
Diagnosis.
Endoscopy demonstrates the gastritis and
a free reflux: of bile.
treatment is conversion of the Billroth I or
II gastrectomy to a Roux-en-Y anastomosis
 Afferent loop syndrome
is caused by intermittent mechanical
obstruction of the afferent loop of a
gastrojejunostomy.
1. Symptoms include early postprandial
distention, pain, and nausea, which are
relieved by vomiting of bilious material
not mixed with food.
2. Treatment consists of providing good
drainage of the afferent loop, usually by
conversion to a Roux: -en-Y anastomosis.
Dumping syndrome
• Affects most postgastrectomy patients but is a significant problem in only a few. It
exists in either an early or late form with the former occurring more frequently.
• Early dumping syndrome occurs within 20-30 minutes following ingestion of a
meal. It is more common after partial gastrectomy with Billroth II reconstruction. It
results from the rapid movement of a hypertonic food bolus into the small
intestine. Rapid fluid shifts into the small bowel cause distention and a subsequent
autonomic response along with the release of several humoral agents.
• Late dumping syndrome occurs 2-3 hours after a meal and is far less common. The
large carbohydrate load passed into the small intestine causes on over-release of
insulin resulting in profound hypoglycemia. This stimulates the adrenal gland to
release a large amount of catecholamines producing confusion tachycardia,
lightheadedness and tremulousness.
Signs and symptoms may include epigastric fullness or pain, nausea,
palpitations, dizziness, diarrhea, tachycardia, and elevated blood
pressure.
Treatment:
• Conservative nonsurgical measures include octreotide to control
symptoms. Patients are advised to avoid a high-carbohydrate diet and
not to drink fluids with meals.
• Surgical treatment is used to delay gastric emptying, including
interposition of an antiperistaltic jejunal loop between the stomach
and small bowel or conversion to a long limb Rouxen-Y reconstruction.