GASTRIC CANCER

Dr Namerah Nasir
Postgraduate Trainee
Surgery
ANATOMY OF STOMACH
• J Shaped structure.
• Two surfaces - Anterior and Posterior
• Two curvatures – the greater and the lesser curvature
• Two orifices- the cardia and the pylorus
The stomach is divided into four regions.
• Cardia – which surrounds the opening of the esophagus
into the stomach
• Fundus – which is the area above the cardial orifice
• Body – which is the largest part of the stomach
• Pyloric part – divided into pyloric antrum and pyloric canal
and is the distal end of the stomach
ARTERIAL BLOOD SUPPLY:
3 Branches
• Left Gastric Artery – Supplies the cardia of the stomach
and distal esophagus
• Splenic Artery – Gives rise to 2 branches which help
supply the greater curvature of the stomach
» Left Gastroepiploic OR Left gastro-omental artery
» Short Gastric Arteries
• Common Hepatic or Proper Hepatic Artery – 2 major
branches
» Right Gastric-
supples a portion of the lesser curvature
» Gastroduodenal artery
-Gives rise to Right Gastroepiploic artery OR gastro-
omental artery
-helps supply greater curvature in conjunction with
Left Gastroepiploic Artery
• The corresponding veins drain into portal system. The
lymphatic drainage of the stomach corresponding its
blood supply.
• NERVE SUPPLY
Sympathetic supply through splanchic nerves (T5-6 to T9-
10)
Sympathetic fibres subserve visceral sensation and pain
Parasympathetic supply: Vagus nerve
HISTOLOGY
Consist of four layers
• Mucosa – Surface Epithelium, Lamina propria, Muscularis
Mucosa
• Submucosa
• Muscularis externa- Oblique layer, Circular layer,
longitudinal layer
• Serosa
GASTRIC CANCER
• Incidence rates:
22 and 10.3 per annum in males and females
respectively.
• 3rd most common cause of male cancer and 2nd most
common cause of male cancer death
• 5th most common cause of female cancer and 4th most
common cause of female cancer death.
• Males are effected twice more than females.
• Both sexes are strongly related to age i.e. between 60 to
80 years old at diagnosis.
AETIOLOGY
• Hereditary
• Germ line mutation of E-cadherin gene CDH1
• H-pylori ( one of the most important factor in both intestinal
and diffuse gastric cancer)
6 fold higher risk.
H pylori Infection > Atrophic gastritis and intestinal
metaplasia > Increased risk of developing gastric cancer
• Alcohol intake
• Smoking
• Excessive salt intake
• Obesity
• Higher socioeconomic status
Sites
• Proximal stomach – most common site.
lower esophagus along with cardia and esophageal gastric
junction makes up 60%.
• Body- 15%
• Antrum 13%
• Pylorus 7%
Pathology
• Lauren classification
2 forms of gastric cancer:
 Intestinal gastric cancer: the tumour resembles a
carcinoma elsewhere in the tubular gastrointestinal tract
and forms polypoid tumours or ulcers. It probably arises in
areas of intestinal metaplasia.
 Diffuse gastric cancer: ( often with signet ring cells)
infiltrates deeply into the stomach without forming obvious
mass lesions, but spreads widely in the gastric wall.
MUCH MORE WORSE PROGNOSIS.
Japanese classification
• Early gastric cancer : cancer limited to the mucosa and
submucosa with or without lymph node involvement (T1,
any N). It can be protruding, superficial or excavated in
the Japanese classification.
• This type of cancer is eminently curable, and even early
gastric cancers associated with lymph node involvement
have 5-year survival rates in the region of 90%.
Japanese Classification
• Type I - Protuded type
• Type IIa - Superficial
and elevated type
• Type IIb - Flat
• Type IIc - Superficial
and depressed type
• Type III – Excavated
type
• Advanced gastric cancer involves the muscularis. Its
macroscopic appearances have been classified by
Bormann into four types.
• Types III and IV are commonly incurable.
The Spread
• 4 ways
Direct spread: The tumour penetrates the muscularis,
serosa and ultimately adjacent organs such as the
pancreas, colon and liver.
Lymphatic spread: Extensive
Blood borne: occur first to the liver and then to other
organs, including lung and bone. Uncommon without nodal
disease.
Transperitoneal spread
common mode of spread once the tumour has reached
the serosa of the stomach and indicates incurability.
Clinical features
• Advanced gastric cancer are usually obvious
• Curable disease have symptoms similar to benign
dyspepsia no associated anemia, dysphagia or weight
loss.
• Patients may present with
Epigastric pain
Loss of apetite
Weight loss
Bleeding
Obstruction
Iron deficiency anemia
• Dysphagia: more common with proximal gastric tumors
• Occult GI bleeding very common, overt bleeding <20%.
• Palpable abdominal mass: most common physical
• finding
• If cancer spreads via lymphatics…
Left supraclavicular node (Virchow’s)
periumbilical node (Sister Mary Joseph)
Left axillary node (Irish)
Enlarged ovary (Krukenberg's tumor)
Ascites
Investigations
• Routine blood examination
low hemoglobin , high ESR
• Stool examination for occult blood
• Endoscopy – helpful in diagnosing early cases and taking
biopsy – Gold Standard for diagnosis
• Ultrasonography - helps in assesing thickening of gastric
wall, local invasion, peritoneal involvement , ascites
• CT scan - extent of the disease , lymph node
involvement , liver metastasis
• Barium studies
• Staging laproscopy
Staging
• CT scan with contrast
Initial staging
multiple planar reconstruction of the thorax, abdomen and
pelvis to determine the presence of metastasis.
• Endoscopic Ultrasound
Not a routine investigation for all gastric cancers
Main Indications:
to determine the extent of proximal gastric leison on GEJ
Confirms early leisons
Examine invasion to pancreas and other structures
• Staging Laproscopy
Direct visualization of low volume peritoneal and liver
disease.
Peritoneal Lavage and cytology is integral component
to ensure absence of small peritoneal disease
Laproscopy will upstage the disease as peritoneal and
liver diseases are not seen on CT
• PET scan
Not a routine investigation in staging gastric caner
May show distant metastatic disease
It can be negative with mucinous and diffuse tumors
TNM Classification
• Primary tumor (pT)
• TX: Primary tumor cannot be assessed
• T0: No evidence of primary tumor
• Tis: Carcinoma in situ: intraepithelial tumor without invasion of the lamina
propria; high grade dysplasia
• T1: Tumor invades the lamina propria, muscularis mucosae or
submucosa
• T1a: Tumor invades the lamina propria or muscularis mucosae
• T1b: Tumor invades the submucosa
• T2: Tumor invades the muscularis propria
• T3: Tumor penetrates the subserosal connective tissue without invasion
of the visceral peritoneum or adjacent structures
• T4: Tumor invades the serosa (visceral peritoneum) or adjacent structures
• T4a: Tumor invades the serosa (visceral peritoneum)
• T4b: Tumor invades adjacent structures/organs
• Regional lymph nodes (pN)
• NX: Regional lymph nodes cannot be assessed
• N0: No regional lymph node metastasis
• N1: Metastasis in one or two regional lymph nodes
• N2: Metastasis in three to six regional lymph nodes
• N3: Metastasis in seven or more regional lymph nodes
• N3a: Metastasis in seven to 15 regional lymph nodes
• N3b: Metastasis in 16 or more regional lymph nodes
• Distant metastasis (pM)
• M0: No distant metastasis
• M1: Distant metastasis

• Distant metastasis include peritoneal seeding, positive

peritoneal cytology and omental tumor
Stage Grouping
• Stage 0: Tis N0M0
• Stage IA: T1N0M0
• Stage IB: T1N1M0 T2N0M0
• Stage IIA: T1N2M0 T2N1M0 T3N0M0
• Stage IIB: T1N3aM0 T2N2M T3N1M0
T4aN0M0
• Stage IIIA: T2N3aM0 T2N2M0 T4aN1-2M0
T4bN0
• Stage IIIB: T1-2N3bM0 T3-4aN3aM0 T4bN1-2M0
• Stage IIIC: T3-4aN3bM0 T4bN3a-3bM0
• Stage IV: any T an y N M1
Lymph Node Stations
Management of Gastric Cancer
• Multidisciplinary team
Surgeons
Gasgtroenterologists
Oncologist
Pathologist
Interventional radiologists
Palliative team
Specialist Nurses
Endoscopic Treatment
Indications:
• When adenocarcinoma is differentieted and confined to
musosa
• Elevated leisons < 2cm
• Depressed type without an ulcer in < 1cm
Interventional mucosal resection
• Submucosal injection of N/S with diluted epinephrine
• Flat leison converted to polypoid leison
• Dissection
• Complete resecion rate is around 50-70%
Endoscopic Mucosal Resection
• Hypertonic saline e diluted epinephrine injected
submucosally around the leison
• Circumfencial insicision with a needle knife
• Resection with electrosurgical snare
• Complete envelop resection of leison
EMR with cap fitted method
• Suction leison by cap fitted endoscope
• Enblock resection
circumferential incision
Endoscopic submucosal dissection ESD
• Direct dissection of submucosal layer of early gastric
cancer
• Enables complete resection
SURGERY
• Mainstray curative treatment
Curative Surgery
Palliative surgery
Extent of Gastric resection
• T2 or deeper tumor growth pattern type 1 and 2
3cm proximal margins
• T2 or deeper tumor growth pattern type 3 and 4
5cm proximal margins
• Tumor invade gastroesophageal junction
5cm margins may not be achieved therefore a frozen
section is recommended for R0 resecion
• T4 or node positive tumors:
total or distal gastrectomy
• Proximal gastric tumors invading GEJ
Gastrectomy with esphagectomy
• If tumor invading the esophagus is <2 cm
Total abdominal approach with transhiatal resection of
lower esophagus and lower mediastinal lymph nodes
• If tumor extend >2 cm inoesophagus
Left thoracolaprptomy, total gastrectomy with lower
esophagectomy with Roux en Y esophagojujenal
reconstruction
• R0 resection
It is a macroscopic margin negative resection, In which
no gross or microscopic tumor remains in the primary tymor
bes
• R1
removal of all the macroscopic disease but microscopic
margins are positive
• R2
Presence of gross residual disease
Omentectomy
• It is done for T3 or debulked tumors
• Bursectomy has a survival benefit in T3 and T4a tumors
• Tumors Penetrating serosa or posterior gastric wall:
Complete bursectomy including pancreatic capsules
performed with aim to remove microscopic tumor deposits
in lesser sac
• Bursectomy should be avoided in T1-T2 tumors to reduce
the risk of pancreatic injury
Lymph Node Dissection
• The principle is
D1 or D1+ lymphadenectomy is indicated for T1N0 tumors
D2 is indicated for N+ or T2-T4 tumors
D1
LN station 1-7
D1+
D1 +LN station 8a 9 11p
D0
Lymphadenectomy <D1
D2
D1, 8a, 9, 9, 10,11p,11d,12a
Total Gasrectomy
• Upper midline incision given
• Stomach is removed enblock
• Removal of greater omentum
• Transverse colon completely sseparated from greater omentum
• The cubpyloric nodes are dissected and the 1st part od
dudenum is divided
• Hepatic nodes are dissected down to clear the Hepatic artery
and dissection of subpyloric nodes
• The R gastric artery is taken doen on Hepatic artery
• The LN dissection is cintinued to the origin of the left gastric
artery
• Left gastric artery is divided flush from its origin
• The dissection is continued along the splenic artery
• Separate stomach from spleen
• The esophagus is divided at an appropriate point using a
combination of sutures and a soft non crushing clamp
• Rection margins should be well cear of tumor (>5cm)
• Gastrointestinal contunity is reconstructed by roux lop
• Alimentary limb of Roux should be at least50cm long to
avoid bile reflux esophagitis (esophagojejunostomy)
• The traditional radical gastrectomy removes spleen and
distal pancreas en block
• The japanese D2 gastrectomy will commonly preserve
spleen and pancreas
Subtotal Gastrectomy
• This is for tumors distally placed in stomach
• Proximal stomach is preserved
• Close the stomach from lesser curvature near
esophagogastric junction then an anastomosis is
performed between greater curve to jejunum (Roux enY
gastro jejunostomy) and then jejunojejunostomy is done.
Palliative Surgery
• This is performed in patients suffering from significant
symptoms of either obstruction or bleeding palliative
resection is appropriate
• A palliative surgery need not to be radical
• Remove the tumor and reconstruct the GIT
• For inoperable tumors particularly in cardia the palliative
intubation or stenting(recanalization) can be used
Perioperative Chemotherapy
• 3cycles of preoperatove and postoperative chemotherapy
ECF
Epirubin (E) 50 mg/m2
Cisplatin (C) 60mg/m2
5 Flurouracil (F)

• 5%survival rate increses from 23% with surgery a lot to

36.3%
Postoperative Chemotherapy
• 5 cycles of postoperative chemotherapy 5FU/ leucovonn
before during and after radiotherapy resulting in 15%
improvement in overall survival
Radiotherapy
• It has a significant role in palliative treatment of bony
metastasis
RELAPSE
• MC site for relapse is Gastric bed
• Widespread nodal involvement metastasis
• Distant nodal metastasis
• Liver metastasis
References
• Bailey and Love short practice of surgery 27th edition
• Alfred cuscheri essential surgical practice 5th edition