Carcinoma Stomach ( Gastric Carcinoma )

Management - Shriyans Jain

When do you suspect ?

• Clinical Features– Symptoms suggestive of a malignancy ?– Signs ?

Differential diagnosis ?

Differentials

• Acid peptic disease, pyloric stenosis with gastric outlet obstruction.

•Gastritis

•Pancreatic mass

•Transverse Colon mass

Investigations

• Flexible Endoscopy• Contrast radiology• Ultrasonography ( Endoscopic USG – EUS )• CT Scan and MRI• PET – CT• Laparoscopy

To confirm the diagnosis

• Flexible Upper GI Endoscopy with directed biopsy followed by histopathological examination of the sample.

Flexible Upper GI EndoscopyEGD (esophago gastro duodenoscopy)

• Visual examination of the upper intestinal tract using a lighted, flexible fiberoptic or video endoscope

• Gold standard • More sensitive than conventional radiology ( 95% accuracy )• Advantages

– Outpatient procedure– No radiation Exposure– Targeted biopsy from the lesion can be taken at the same setting.– Diagnosis can be made more accurately

Indications

• Ulcers in the upper GI tract• Tumors of the stomach or esophagus• Severe/Persistent Dysphgia• Undiagnosed Upper abdominal pain or

indigestion • Intestinal bleeding• Esophagitis and heartburn – unresponsive to

medical therapy• Gastritis

Contraindications

• Shock• Acute MI• Peritonitis• Acute perforation• Corrosive injuries of Oesophagus

Gastric Carcinoma – Intestinal Type Gastric Carcinoma – Diffuse Type

Contrast Radiology

• Single Contrast/ Double Contrast• Barium Meal• Advantages– Sensitivity comparable to endoscopy– Non Invasive procedure

Carcinoma of the gastric antrumStomach – Normal Duble contrast barium study

Gastric Carcinoma of the body and Carcinoma along the greater curvatureproximal antrum ( Ulcerative lesion with filling defect )(Multiple small ulcerations )

Findings in Carcinoma Stomach

• Irregular filling defect• Loss of rugosity• Delayed emptying• Dilatation of stomach in carcinoma pylorus• Decreased stomach capacity in linitis plastica• Carmanns meniscus sign

Ultrasonography

• Endoscopic / Endoluminal Ultrasound is useful to detect the involvement of layers of the stomach, nodal status and to differentiate early from advanced cancer.

• Excellent at determining the T- Stage ( 90% )• High frequency probes used to differentiate T1-

2 stage• Nodal status can also be assessed• Limited use in advanced disease

The white arrow indicates the tumour invasion The black arrow indicares the muscularis propria

A – TI stage – Tumour localized to the mucosa and sub mucosaB – T2 stage – Tumour invades the muscularis propriaC – T3 stage – Tumour invades subserosa and abuts the surrounding structures

( here Aorta )

Chest X-ray

• Look for– Lung metastases– Pleural Effusion

USG abdomen

• Liver metastases

Computed tomography and MRI

• Every patient with a histological diagnosis of gastric Carcinoma should undergo a Ct of the chest and abdomen.

• Provides information about – M stage ( Liver, Lung, Peritoneum and distant

nodes )– T4 stage ( involvement of the adjacent structures )

Localized versus Diffuse thickening

Secondaries from Carcinoma Stomach in the Liver and the Lung

Laproscopy

• To stage the disease especially in locally advanced tumours– Peritoneal secondaries– Occult metastases– Organ invasion– Peritoneal lavage for cytology– Biopsy of peritoneum and nodes

Signs of inoperability

• Peritoneal deposits• Fixity• Liver secondaries• Fixed iliac nodes• Para aortic nodes• Ascitic fluid positivity• Sister Mary Joseph Nodule• Left axillary lymph node secondaries

Other tests

• Left Supraclavicular Node biopsy• Tetracycline flourescence test• CA 72-4 in relapse, CEA, CA 19-9, CA 12-5• Combined PET – CT• Sentinel Node biopsy• HB, Hematocrit, LFT, PT

Treatment

Multidisciplinary Team

• Surgery• Chemotherapy• Immunotherapy• Radiotherapy• Oncology and• Palliative Care

Goal of Treatment

• Resection of all tumor

• All margins (proximal, distal, and radial) should be negative and an adequate lymphadenectomy performed

• Negative margin of at least 5 cm

Lymph node Stations

Japanese Research Society of Gastric Cancer

• 1 Right paracardial LN• 2 Left paracardial LN• 3 LN along the lesser curvature• 4sa LN along the short gastric vessels• 4sb LN along the left gastroepiploic vessels• 4d LN along the right gastroepiploic vessels• 5 Suprapyloric LN• 6 Infrapyloric LN

N 1 Group ( First tier of lymph nodes )

• 7 LN along the left gastric artery• 8a LN along the common hepatic artery

(Anterosuperior group)• 8p LN along the common hepatic artery(Posterior

group)• 9 LN around the celiac artery• 10 LN at the splenic hilum• 11p LN along the proximal splenic artery• 11d LN along the distal splenic artery• 12a LN in the hepatoduodenal ligament (along the hepatic artery)• 12b LN in the hepatoduodenal ligament (along the bile duct)• 12p LN in the hepatoduodenal ligament (behind the

portal vein)

N 2 Group (Second tier of lymph nodes )

• 13 LN on the posterior surface of the pancreatic head• 14v LN along the superior mesenteric vein• 14a LN along the superior mesenteric artery• 15 LN along the middle colic vessels• 16a1 LN in the aortic hiatus• 16a2 LN around the abdominal aorta (from the upper margin

of the celiac trunk to the lower margin of the left renal vein)• 16b1 LN around the abdominal aorta (from the lower margin of the left renal vein to the upper margin of the inferior mesenteric artery)• 16b2 LN around the abdominal aorta (from the upper margin of the inferior mesenteric artery to the aortic bifurcation)• 17 LN on the anterior surface of the pancreatic head• 18 LN along the inferior margin of the pancreas

• 19 Infradiaphragmatic LN• 20 LN in the esophageal hiatus of the diaphragm• 110 Paraesophageal LN in the lower thorax• 111 Supradiaphragmatic LN• 112 Posterior mediastinal LN

Surgical Resection of the tumour

• Based on the TNM staging – Patients with early gastric cancer should undergo

a subtotal or total D2 gastrectomy– Patients with advanced disease should undergo

multi-modality treatment with neoadjuvant chemotherapy and surgery

Based on site of the tumour

• Pylorus Lower radical Gastrectomy ( proximal 5cm clearance with removal

of greater omentum , lesser omentum, lymph nodes, spleen, tale of pancreas )

• OG junction Upper Radical Gastrectomy ( Total Gastrectomy is ideal )

(removal of greater omentum , lesser omentum, lymph nodes, spleen, tale of pancreas )

Sub-Total Gastrectomy

• Linitis Plastica Total Gastrectomy D2 Gastrectomy – Removal of stomach

with growth , both the omentum, omental bursa, anterior layer of mesocolon, anterior pancreatic capsule, D2 lymphadenectomy )

Distal Clearance towards duodenum is 1cm from the tumour end

Lymph node dissection

• D0 No dissection or incomplete dissection of the Group 1 nodes

• DI Group 1 lymph nodes (LN)• D2 D1 + Group 2 LN• D3 D2 + Group 3 LN• D4 D3 + para-aortic nodes

Reconstruction procedures

• In case of sub total or partial gastrectomy, Billroth II Anastomosis may be tried.

Roux-en-Y Oesophagojejunostomy• Bypasses the stomach• Done in cases of subtotal or total gastrectomy

Post op complications

Early complications

• Paralytic ileus.• Leakage from suture line.• Leakage from duodenal stump.• Acute Cholycystitis, Pancreatitis• Stomal obstruction.

Title Late complications

• Early Dumping syndrome • Late dumping syndrome.• Bilious vomiting.• Gastric stump cancer• Vit B12 deficiency • Osteoporosis

Adjuvant Therapy

• Rationale behind radiotherapy is to provide additional local-regional tumor control.

• Adjuvant chemotherapy is used either as a radiosensitizer or as definitive treatment for presumed systemic metastases.

Adjuvant Radiotherapy• lower rates of local recurrence in patients who

received postoperative radiotherapy than in those who underwent surgery alone

(British stomach cancer study group)

• Improved survival (mayo clinic randomized patients)

Intra operative radiotherapy

• allows for a high dose to be given in a single fraction while in the operating room so that other critical structures can be avoided.

• Stage 3 and 4

• Median survival (21 months vs 10 months ) with IORT

Adjuvant Chemotherapy

• No consistent survival benefit.

• Epirubicin . 5 florouracil ,cis platinium (ECF)

• Combination of chemoradio therapy has better outcome

Neo adjuvant chemotherapy

• downstaging of disease to increase resectability,

• decrease micrometastatic disease burden prior to surgery

• allow patient tolerability prior to surgery• determine chemotherapy sensitivity• reduce the rate of local and distant

recurrences, and ultimately improve survival.

Palliative Care

• radiotherapy provides relief from bleeding, obstruction, and pain in 50-75%

• wide local excision, partial gastrectomy, total gastrectomy, simple laparotomy, gastrointestinal anastomosis, and bypass for food intake or pain relief

Summary

Prognostic Factors

• Early vs advanced• Histological grading• Staging• Gross types• Lymph node status• Liver secondaries• Serosal involvement• Diffuse vs intestinal• Ascites• Response to treatment

PrognosisStage 5 year Survival (%)

T1N0M0 95+

T1N1M0 70 - 80

T2N1M0 45 - 50

T3N2M0 15 - 25

M1 0 - 10

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