COMMON
GASTROINTESTI
NAL
MALIGNANCIES
Kristine Flor D. Renomeron
Group 2
Schwartz Club
A 65-year-old male presented with hematemesis &
melena on an emergency basis. He has been vague upper
abdominal pain and feeling of an abdominal lump on and
off for two years. On examination, clinical examination
of the abdomen revealed a well-defined transversely
mobile intra-abdominal lump in the right hypochondrium
of about 8 × 6 cm.
Ultrasound
Findings
1 2 3
Outline the steps involved in Demonstrate an understanding of Acquire overview of the
the clinical diagnosis and the relevant anatomy that staging and prognosis of the
management of determines the strategy and extent common malignancies noted
gastrointestinal Malignancies of resection employed in the above
management of gastrointestinal
malignancies
Objectives
Outline
■ Carcinoma
■ Lymphoma
■ Gastrointestinal Stromal Tumor (GIST)
■ Neuroendocrine tumor
ADENOCARCINO
MA
Adenocarcinoma
■ Fourth most common cancer type and the second
leading cause of cancer death world- wide
■ Disease of the elderly
■ Higher incidence in groups of lower socioeconomic
status
Etiology
■ Common in patients with pernicious anemia, blood
group A, or a family history of gastric cancer
■ Evidence suggests environment has a great effect
Risk Factors: Increased Risk
■ Family history
■ Diet (high in nitrates, salt, fat)
■ Helicobacter pylori infection
■ Previous gastrectomy or
gastrojejunostomy (>10 y ago)
■ Ménétrier’s disease
Gastric Carcinogenesis
Chronic
Atrophic
Normal Superficial
Gastritis
Gastritis
Intestinal
Dysplasia Cancer
Metaplasia
MACROSCOPIC TYPE OF GASTRIC CANCER
Type 0-I (Protruding ) Polypoid tumors
Type 0-II (Superficial) Tumors with or without minimal
elevation or depression relative
to the surrounding mucosa
Type 0-IIa Slightly elevated tumors
(superficial elevated) PATHOLOG
Type 0-IIb Tumors without elevation or
depression (superficial flat)
Y
Type 0-IIc Slightly depressed tumors
(superficial depressed)
Type 0-III (excavated) Tumors with deep depression
Schwartz’s Principle of Surgery, 11th Edition
PATHOLOGI
C TYPES OF
EARLY
GASTRIC
CANCERS
INTESTINAL TYPE
DIFFUSE TYPE
PATHOLOGIC
STAGING
■ Weight loss + anorexia +
early satiety
■ Abdominal pain, nausea,
Clinical vomiting , bloating,
Manifestations: abdominal mass
■ UGIB, dysphagia
Symptoms
■ Paraneoplastic syndrome,
Trosseu Syndrome,
Acanthosis nigricans
Sign Description
Virchow node Left supraclavicular
Lymphadenopathy
Irish node Axillary lymphadenopathy
Clinical Krukenberg Metastasis to the ovary
Manifestations: tumor
Signs Sister Mary Periumbilical lymph node
Joseph nodule
Blumer shelf Solid peritoneal deposit
anterior to the rectum
forming a shelf
DIAGNOSTIC
EVALUATION
Endoscopy
■ Patient over 55 years old.
■ New onset dyspepsia ± Warning Signs
■ Family history of gastric cancer
MAGNIFYING ENDOSCOPY WITH
NARROW-BAND IMAGING (NBI)
■ Observe the microvascular architecture of the mucosa and micro
surface pattern of the lesion.
Double-contrast barium upper GI
examination
■ Up to 75% sensitive for gastric tumors
Abdominal/Pelvic CT Scan
■ With IV and Oral Contrast
Endoscopic Ultrasound
■ Best way to stage the tumor locally
■ Gives information about the depth of tumor penetration into
the gastric wall, and can usually show enlarged (>5 mm)
perigastric and celiac lymph nodes
Positron Emission Tomography
Screening
■ Accumulation of positron-emitting 18F-fluorodeoxy glucose in
tumor
■ Useful in the evaluation of distant metastasis
Staging Laparoscopy and Peritoneal
Cytology
■ Rapid identification of macroscopic peritoneal metastases
■ Identifies an additional subset of patients with microscopic
dissemination
MANAGEME
NT
Surgical Resection
■ Only potentially curative treatment for gastric cancer
■ Goals of curative surgical treatment are resection of all tumor
■ Surgeon strives for a grossly negative margin of at least 5 cm
■ For diffuse tumors, wider gross margins guided by frozen section are
sometimes appropriate
■ Surgeon should determine whether the microscopic tumor cells are
within the wall or on the serosa
Radical Subtotal Gastrectomy
■ Total gastrectomy confers no additional survival benefit
■ Ligation of the left and right gastric and gastroepiploic arteries at
their origins, as well as the en bloc removal of the distal 2/3 of the
stomach, including the pylorus and 2 cm of duodenum, the greater
and lesser omentum, and all associated lymphatic tissue
■ Reconstruction is usually by Billroth II gastrojejunostomy or Roux-
en-Y gastrojejunostomy.
BILLRO
TH II
Roux-en-Y
Gastrojejunostomy
BILLRO
TH 1
Extent of
Lymphadenectomy:
Distal gastrectomy
■ D1
lymphadenectomy:
dissection of stations
1, 3, 4sb, 4d, 5, 6, and
7
■ D2: D1 + resection of
stations 8a, 9, 11p,
and 12a
Extent of
Lymphadenectomy
: Total Gastrectomy
■ D1 lymphadenectomy:
dissection of stations 1
through 7
■ D2 lymphadenectomy:
D1 + 8a to 12a as well
Chemotherapy and Radiation
■ Adjuvant therapy is indicated in the majority of patients who
undergo initial resection
■ Chemotherapy with 5-fluorouracil and leucovorin and radiation
(4500 cGy) demonstrated a survival benefit in resected patients
with stage II and III adenocarcinoma of the stomach.
■ Neoadjuvant chemotherapy has emerged as a viable alternative to
adjuvant chemoradiotherapy
Endoscopic Resection
■ For patients in whom the probability of lymph node metastasis
is low
■ Well differentiated gastric cancer confined to the mucosa
(T1a), measuring less than 2 cm and without signs of
ulceration
■ Allows en bloc resection of larger tumors
GASTRIC
LYMPHOMA
Gastric Lymphoma
■ stomach is the most common site of primary GI lymphoma, and over
95% are non-Hodgkin’s type.
■ H. pylori infection is thought to be a risk factor
■ Half are histologically half grade, half are histologically high grade
DIAGNOST
IC
EVALUATI
ON
Diagnostic Evaluation
ENDOSCOPY BIOPSY CT SCAN: IMMUNOHIST
GOOD FOR OCHEMISTRY
STAGING
MANAGEME
NT
GASTROINTESTIN
AL STROMAL
TUMOR
Gastrointestinal Stromal Tumors
■ Arise from interstitial cells of Cajal (ICC)
■ Most common type: Epithelial cell stroma
■ Mutations in the KIT oncogene result in the activation
of the KIT receptor Tyrosine Kinase
HISTOPATHOLOG
Y: EPITHELIOID
TYPE
HISTOPATHOLOG
Y: SPINDLE CELL
TYPE
DIAGNOST
IC
EVALUATI
ON
■ Tumor Marker: CD117 and CD34
■ Endoscopy + Biopsy
■ Chest, abdominal, pelvic CT Scan
MANAGEME
NT
Surgical Resection
First line of treatment: complete Long term follow up is warranted
resection with negative margins for all patients
Imatinib
■ Primary therapy for metastatic GIST
■ Selectively inhibits KIT Receptor
■ For unresectable or metastatic GIST
Continuation of the
case..
■ The abdomen was explored electively and a 10 × 6
cm tumor was seen arising from the greater curve
of the stomach, exophytically, with a sessile base.
There was no infiltration of the mass into the
surrounding structures, nor any evidence of
metastases or lymphadenopathy.
GASTRIC
NEUROENDOCRI
NE TUMOR
Gastric Neuroendocrine Tumors
■ They arise from gastric enterochromaffin-like (ECL) cells
GASTRIC NEUROENDOCRINE
TUMORS CLASSIFICATION
Characteristic Type I Type II Type III
% among gastric 70-80 5-10 10-15
carcinoids
Associated Disease Atrophic Gastritis Gastrinoma None
Helicobacter pylori MEN 1
Gastric pH High (>4) Low (<2) Normal
Serum Gastrin High High Normal
Schwartz’s Principle of Surgery, 11th Edition
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