CARCINOMA STOMACH Etiology, clinical features.pptx

This presentation has brief information about carcinoma stomach introduction, information gathered from Bailey and love text book of surgery , management is not covered in this presentation

1. CARCINOMA STOMACH (Etiology , c/ f, spread) Dr Ch. R. Chalam Associate Professor General Surgery Guntur Medical College

2. ETIOLOGY H. pylori – principally associated with carcinoma of body and distal part of stomach rather than proximal part. Pernicious anemia . Gastric atrophy . Gastric adenomatous polyp . Surgery for PUD with drainage procedures ( Billroth II , polya gastrectomy, gastroenterostomy, pyloroplasty – associated with bile reflux and intestinal metaplasia that increases risk of ca stomach by 4 times average risk. Cigarette smoking ; alcohol consumption. Dust ingestion from industrial processes Dietary- increased salt intake, deficiency of antioxidants, increased N- nitroso compounds in food Proximal gastric cancer is associated with obesity, higher socio economic status.

3. CLINICAL FEATURES If detected early has higher curative rates Has no specific features to differentiate from benign dyspepsia Needs high index of suspicion for early diagnosis Symptoms: Anorexia, symptoms of Anemia , Asthenia in a young man. Dyspepsia - Early satiety, epigastric fullness, bloating, distension, Haematemesis , malena as tumor tends to bleed. Dysphagia.- if gastric cardia is involved Vomitings - if there is GOO.( tumor involving pylorus). Features of metastases- cough, Haematemesis , bone pain, etc.....

4. Signs: Iron deficiency anemia Epigastric lump- with intrinsic mobility/ fixed. Features of GOO- Succussion’s splash, visible gastric peristalsis from left to right. Ascites Features of distant metastases to liver, lung and bone. Blummer shelf – in P/R Kruckenburg tumor – in P/V Trousseau’s sign – non metastatic effect on thrombotic and haemostatic mechanism Trousier’s sign

5. SPREAD OF CA STOMACH The intestinal and diffuse types of gastric cancer spread differently. The diffuse type spreads via the submucosal and sub serosal lymphatic plexus and penetrates the gastric wall at an early stage. DIRECT SPREAD – tumor penetration through muscularis , serosa into adjacent organs (pancreas, colon, liver) LYMPHATIC SPREAD – permeation and emboli to affected tiers of nodes, nodal involvement doesn’t mean systemic dissemination if extensive involves lt supra clavicular nodes – TROISIER’S SIGN BLOOD BORNE Metastasis- uncommon in absence of nodal involvement first occurs in liver and then lungs and bone.

6. JAPANESE CLASSIFICATION OF LN STATIONS

7. Lymph node stations in gastric carcinoma (Japan)—18stations are there 1. Right cardiac 2. Left cardiac 3. Nodes along the lesser curvature 4. Nodes along the greater curvature. Along short gastric vessels—4sab. Along left gastroepiploic vessels—4sbc. Along right gastroepiploic vessels—4sd 5. Suprapyloric nodes 6. Subpyloric nodes 7. Along left gastric artery 8. Along common hepatic artery 9. Along celiac axis 10. At splenic hilum

8. 11. Along splenic artery 12. At hepatoduodenal ligament 13. Retroduodenal lymph nodes 14. At root of mesentery 15. Around middle colic artery 16. Para-aortic nodes 17. Around lower oesophagus 18. SupradiaphragmaticFirst tier nodes: Nodes within 3 cm from primary tumour(stations 1-6)—N1 (old TNM)Second tier nodes: Nodes in main and intermediate arterialtrunk (stations 7-11)—N2 (old TNM)Third tier nodes: Nodes at stations 12-18 (para-aortic andabove )—N3 (old TNM)Note: 15 lymph nodes must be removed for adequate staging of nodes

9. TRANSPERITONEAL SPREAD This is a common mode of spread once the tumor has reached the serosa of the stomach and indicates incurability. Tumors can manifest anywhere in the peritoneal cavity and commonly give rise to ascites. Advanced peritoneal disease may be palpated either abdominally or rectally as a tumor ‘shelf ’. The ovaries may sometimes be the sole site of trans coelomic spread Krukenberg’s tumors . Tumor may spread via the abdominal cavity to the umbilicus Sister Joseph’s nodule . Transperitoneal spread of gastric cancer can be detected most effectively by laparoscopy and cytology.