Malignancy of the stomach and other stomach dysplasia.pptx

Malignancy of the stomach

1. Malignant neoplasms of the stomach DR MASSAM

2. Objectives By the end of this presentation, students should be able to: Describe the surgical anatomy of the stomach Describe risk factors and histological subtypes of Gastric cancer. Take a focused history and examine a patient suspected to have gastric cancer. Outline the diagnostic and metastatic investigations of gastric cancer patient Describe the pre-referral management of a patient with gastric cancer

3. Anatomy of stomach

4. Introduction The three most common primary malignant gastric neoplasms are A denocarcinoma (95%), Lymphoma (4%), Malignant gastrointestinal stromal tumor (GIST) (1%) Gastric adenocarcinoma  is a malignant epithelial tumour , originating from glandular epithelium of the gastric mucosa. 

5. Epidemiology Gastric cancer is the 3 rd most common cause of cancer death and 5 th most common cancer worldwide. The incidence is highest in Japan, and Korea Male to female ratio 2 : 1 2x Blacks then whites Older age Shift of site – distal to proximal cardia due to smoking and alcohol abuse

6. Classification WHO Classification: Adenocarcinoma Papillary adenocarcinoma Tubular adenocarcinoma Mucinous adenocarcinoma Signet-ring cell carcinoma Adenosquamous carcinoma Squamous cell Ca Small cell Ca Undifferentiated Ca Others

7. Risk factors Increase risk Family history Diet (nitrates, salt, fat) Familial polyposis Gastric adenomas Hereditary nonpolyposis colorectal cancer Helicobacter pylori infection Previous gastrectomy or gastrojejunostomy (>10yrs) Tobacco use Chronic alcohol consumption Menetrier’s disease – rare disorder xzed by mucosal folds in the stomach Blood type A Decrease risk Aspirin Diet (high fresh fruit and vegetable) Vitamin C

8. Pathogenesis…

9. Clinical features Generally nonspecific and contribute to its frequently advanced stage at the time of diagnosis. Weight loss and Persistent abdominal pain are the most common symptoms at initial diagnosis . Weight loss usually results from insufficient caloric intake & Postprandial fullness. Loss of appetite. Abdominal pain tends to be epigastric, vague and mild (early in the disease) but more severe and constant as the disease progresses. Gastric outlet obstruction , non-bilious vomiting, ( + ) succussion splash. Dysphagia , cancers arising in the proximal stomach.

10. Other clinical features… Early satiety , form of diffuse-type gastric cancer called linitis plastica , from poor distensibility of the stomach. Occult gastrointestinal bleeding with or without iron deficiency anemia. Overt bleeding, melena or hematemesis. Pseudoachalasia syndrome involvement of Auerbach's plexus due to local extension or to malignant obstruction near the gastroesophageal junction.

11. Signs of tumor extension (late feature) Virchow’s node : left supraclavicular node Irish’s node: Left axillary nodes Sister Mary Joseph nodule: Umbilical metastases. Peritoneal spread (transcoelomic) can present with an enlarged ovary Krukenberg's tumor A mass in the cul-de-sac (rectouterine or rectovesicle pouch) on rectal examination or PV exams Blummer's shelf Ascites: P eritoneal carcinomatosis. Palpable liver mass with or without jaundice due to hepatic metastases.

12. Diffuse seborrheic keratoses

13. Acanthosis nigricans

14. Clinical features… Succussion splash test: A sloshing sound heard through stethoscope during sudden mvt of the pt on abdominal examination. It is elicited by placing a stethoscope over the upper abdomen and rocking the pt back and forth at the hips. Retained gastric material greater than three hours after meal will generate a splashing sound indicating the presence of hollow viscus filled with fluid and gas.

15. Diagnosing …. 1) Barium contrast radiographs Single-contrast examinations have a diagnostic accuracy of 80% double-contrast (air and barium) 90% Ulceration, The presence of a gastric mass, Loss of mucosal detail, Distortion of the gastric silhouette

16. Barium contrast radiographs

17. Cont … 2 ) Intraluminal contrast, CT scan reliably demonstrate infiltration Gastric wall by tumor, Gastric ulceration, Hepatic metastasis Less reliable with regard to invasion of adjacent organs or the presence of lymphatic metastases. 40% to 50% accuracy rate for ct scanning in preoperative local staging of gastric carcinoma

18. Endoscopic Ultrasound Excellent at delighting sub epithelial lesions , p erigastric lymph nodes involved. But because of a limited depth of tissue penetration, however, endoscopic ultrasound is unable to detect hepatic metastases. Operator dependent and tends to overestimate the T stage of the tumor, and may underestimate lymph node involvement since normal-sized nodes (<5 mm) can harbor metastases. Accurate in distinguishing early gastric cancer from more advanced tumors.

19. Endoscopy 90% of gastric cancers are detected by upper endoscopy and biopsy In cases of known gastric cancer, endoscopy is helpful to Establish treatment goals (cure or palliation), TNM stage, Assessment of response to previous therapeutic approaches

20. Other modalities CXR PET -scan Staging Laparoscopy reveal small peritoneal implants or liver metastases that were not detected on preoperative imaging studies Peritoneal Cytology

21. Management … Surgery is the only curative treatment for gastric cancer (Gastrectomy) I s the best palliation and provides the most accurate staging. Exceptions :- 1 patients who cannot tolerate an abdominal operation. 2 patients with overwhelming metastatic disease

22. Goal of curative surgical treatment Resection of all tumor. All margins (proximal, distal, and radial) should be negative Adequate lymphadenectomy performed Grossly negative margin of at least 5 cm, since some gastric tumors are quite infiltrative and tumor cells can extend well beyond the tumor mass

23. INTRAOPERATIVE COMPLICATIONS Hemorrhage Acute ischemia of the left lobe of liver Injury to Spleen Pacreas , common bile duct Disruption of Ampulla of Vater

24. POST OPERATIVE COMPLICATIONS IMMEDIATE ( WITHIN 30 DAYS OF SURGERY ) EARLY (W ITHIN 6 MONTHS ) LATE ( AFTER 6 MONTHS )

25. IMMEDIATE COMPLICATION ATELECTASIS 12 – 20 % PNEUMONIA 9% RESPIRTORY FAILURE 3 % PULOMNARY EMBOLISM 0.05% VENOUS THROMBOSIS OF LOWER LIMBS WOUND INFECTION SUBPHRENIC ABSCESS ACUTE PANCREATITIS

26. EARLY COMPLICATIONS POST OPERATIVE ANASTOMOTIC HEMORRHAGE ANASTOMOTIC LEAK DUODENAL STUMP LEAK SMALL BOEL OBSTRUTION STOMAL OBSTRUCTION

27. Management at health center or dispensary Perform conservative management such as :- Insert IV lines for giving IV fluids ( RL, NS or DNS depending on RBG ) Draw blood sample for Hb , BG and X-Match Give anti pain whenever necessary Catheterize the patient to monitor urine output Perform any available imaging Refer to the higher hospital for further management including possible gastrectomy.

28. R efferences Schwartz principles of surgery 10 th edition Subiston textbook of surgery 20 th edition Bailey and love short practice of surgery 27 th edition Greenfield surgery 5 th edition Manipal manual of surgery 4 th edition