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Gastric carcinoma

Anatomy of the stomach

Anatomy of the stomach

Gastric carcinoma

  • Gastric carcinoma is the second commonest cause of cancer deaths world wide
  • Accounts for 7000 deaths per year in the UK

Risk factors

  • Diet low in Vitamin C
  • Blood group A
  • Pernicious anaemia
  • Hypogammaglobulinaemia
  • Post gastrectomy

Precursor states

  • Helicobacter pylori infection
  • Atrophic gastritis
  • Intestinal metaplasia
  • Gastric dysplasia
  • Gastric polyps

Clinical presentation

  • Most present late and are not amenable to radical surgery
  • Upper GI endoscopy should be considered in all with dyspeptic symptoms over 40 years
A small malignant gastric ulcer A large gastric carcinoma extending from the incisura to the pylorus

Staging of gastric carcinoma

  • Requires a combination of preoperative investigations and intraoperative assessment
  • OGD confirms diagnosis, site and extent of tumour
  • Endoscopic ultrasound may allow assessment of intramural tumour penetration
  • CT will assess nodal spread and extent of metastatic disease
  • Laparoscopy will identify peritoneal seedlings
  • Peritoneal lavage will identify free tumour cells

Birmingham Staging System

  • Clinicopathological system
  • Does not require detailed lymph node status
  • Stage 1       Disease confined to muscularis propria
  • Stage 2       Muscularis and serosal involvement
  • Stage 3       Gastric and nodal involvement
  • Stage 4a     Residual disease
  • Stage 4b     Metastatic disease

Survival

  • Prognosis if generally very poor
  • Overall 5 year survival is approximately 5%
  • Survival is 70%, 32%, 10% and 3% for Stages 1,2,3 and 4 respectively

Management

  • Surgery is the only prospective of cure
  • Antral tumours may be suitable for a partial gastrectomy usually with Polya reconstruction
  • Other tumours will need a total gastrectomy with oesophagojejunal anastomosis and Roux-en-Y biliary diversion
  • A tumour is considered resectable if confined to stomach or N1 or N2 nodes involved
  • Nodes less than 3 cm from tumour = N1 nodes
  • Nodes greater than 3 cm from tumour = N2 nodes
  • If tumour and N1 nodes resected = D1 gastrectomy
  • If tumour and N2 nodes resected = D2 gastrectomy
  • Evidence to support the use of D2 gastrectomy is incomplete
  • D2 gastrectomy associated with increased post-operative mortality 
  • May be associated with improved long-term survival
  • Even in patients with incurable disease surgery may palliate symptoms
  • Results from adjuvant chemotherapy post surgery are disappointing
  • Chemoradiotherapy may reduce relapse and improve survival

Intraopeartive appearance of a gastric carcinoma

Picture provided by Miss Avril Chang, Central Middlesex Hospital, London, United Kingdom

Gross pathological appearance of a gastric carcinoma

Linnitus plastica

Picture provided by Shyllashree Chikkamuniyappa, UTHSCSA, San Antonio, USA

Other gastric tumours

Leiomyosarcoma

  • Accounts for 2-3% of all gastric tumours
  • Arises from the smooth muscle of the stomach wall
  • Lymphatic spread is rare
  • 75% present with an upper gastrointestinal bleed
  • 60% have palpable abdominal mass
  • Diagnosis can be confirmed by endoscopy and CT scanning
  • Partial gastrectomy may allow adequate resection
  • 5-year survival is approximately 50%

Gastric leiomyoma

Gastric lymphoma

  • Stomach is the commonest extranodal primary site for non-Hodgkin's lymphoma
  • Accounts for approximately 1% of gastric malignancies
  • Clinically presents similar to gastric carcinoma
  • 70% of tumours are resectable
  • 5-year survival is approximately 25%
  • Both adjuvant radiotherapy and chemotherapy may be useful

Sister Mary Joseph Nodule

  • Sister Mary Joseph was Head Nurse to William Mayo
  • Was first to notice that a 'nodule' in the umbilicus was often associated with advanced malignancy
  • Presents as firm, red, non-tender nodule
  • Results from spread of tumour within the falciform ligament
  • 90% of tumours are adenocarcinomas
  • Commonest primaries are stomach and ovary
  • Primary tumour is almost invariably inoperable

Sister Mary Joseph nodule

Picture provided by Sampurna Tuladhar, B & B Hospital, Katmandu, Nepal

Bibliography

Bryan R T,  Cruickshank N R,  Needham S J et al.  Laparoscopic peritoneal lavage in staging gastric and oesophageal cancer.  Eur J Surg Oncol 2001;  27:  291-297.

Cuschieri A,  Fayers P,  Fielding J et al.  Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer:  Preliminary results of the MRCS randomised controlled surgical trial.  Lancet 1996;  347:  995-999.

MacDonald J S,  Smalley S R,  Benedetti J et al.  Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction.  N Eng J Med 2001;  345:  725-730.

Ravichandran D,  Lamah M,  Carty N J,  Johnson C D.  Extended lymph node dissection (D2 resection) should now be performed in the curative surgical treatment of gastric carcinoma.  Ann R Coll Surg Eng 1995;  77:  431-436.

Sasako M.  Surgery for gastric cancer.  In:  Johnson C D,  Taylor I eds.  Recent Advances in Surgery 23.  Edinburgh:  Churchill-Livingston, 2000;  11-21.

Whiting J L,  Fielding J W.  Radical surgery for early gastric cancer.  Eur J Surg Oncol 1998;  24:  263-266.

 

 
 

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