أسئلة الثالثة عشر جراحة ثالثة الدلتا

• This document is about Gastric Carcinoma

Etiology: Predisposing Factors

• Dietary factors include tobacco, alcohol, spicy food, high salt intake, smoked meat and fish, and a diet rich in nitrosamines, especially common in Japan.
• Infection with H. pylori is a predisposing factor.
• Achlorhydria, often associated with pernicious anemia, is a factor.
• Genetic factors include blood group A, mutations of p53 and APC genes, familial hypogammaglobulinemia, and HNPCC or Lynch syndrome.
• Peptic Ulcers cause 5% of cases.
• Benign Gastric Neoplasms (polyps).
• Following Gastrectomy.

Etiology: Pre-cancerous Conditions

• Achlorhydria.
• Atrophic gastritis.
• Adenomatous gastric polyps.
• Pernicious anemia.
• Peptic ulcer (gastric ulcer).
• Partial gastrectomy (Gastric stump cancer).
• Menetrier disease.

Incidence

• Gastric cancer is more common in Japan than western countries due to environmental disease risks:.
• Men are more likely to be affected by the disease
• In western countries, gastric cancer incidence is decreasing by about 1% per year, specifically in the body and distal stomach.
• There is an increase in the incidence of carcinoma in the proximal stomach.
• Carcinoma of the distal stomach and body is more common in low socioeconomic groups.
• Proximal gastric cancer increase affect higher socioeconomic groups.
• Proximal gastric cancer is not associated with H. pylori infection.

Pathology: Site

• The cardia and fundus represents (5-25%).
• Body represents (15-30%).
• The pyloric antrum represents (60%).
• Diffuse area represents (5%).

Pathology: Early Gastric Cancer (5%)

• Early gastric cancer does not go deeper than submucosa (T1).
• Japanese endoscopic society classification includes Type I (Protruded), Type II (Superficial, elevated, flat, or depressed), and Type III (Excavated).

Pathology: Advanced Gastric Cancer (95%)

• Tumor invades Muscularis (T2 or more).
• Advanced gastric cancer is classified using the Borrmann classification:
• Type I: Polypoidal.
• Type II: Fungating mass (cauliflower mass).
• Type III: Ulcerating.
• Type IV: Diffusely infiltrating (scirrhous).
• Type V: Unclassified.

Pathology: Lauren & Finnish Classification

• Intestinal type (53%) presents carcinoma cells with brush borders.
• The intestinal type consists of neoplastic cells that stick together and form acini when well-differentiated, subtypes include columnar cell, spheroidal cell, and colloid carcinoma.
• Diffuse type (33%) contains neoplastic cells that stream out and invade the stomach wall without forming acini.
• Diffuse type subtypes include colloid and signet ring cell carcinoma.
• Unclassified Carcinoma represents (14%).

Spread: Direct

• Pyloric growth infiltrates the duodenum.
• Fundal growth infiltrates the lower esophagus.

Spread: Blood

• It commonly spreads to the liver via the portal vein, leading to hepatomegaly.
• Spread to the lung, bones, and other organs via systemic circulation is unusual and late.

Spread: Lymphatic

• Zone I (inferior gastric) involves nodes around the right gastroepiploic and gastroduodenal arteries, leading to nodes around the hepatic artery and celiac nodes.
• Zone II (splenic) involves nodes around the left gastroepiploic and short gastric arteries, pancreaticosplenic nodes, splenic artery nodes, and celiac nodes.
• Zone III (superior gastric) involves nodes around the left gastric artery and celiac nodes.
• Zone IV (hepatic) involves nodes around the right gastric artery and celiac nodes.
• Lymphatic permeation involves cancer cells invading lymphatics and forming continuous growth in the lymphatic channels.
• Lymphatic emboli involve detachment of malignant cells to form tumor emboli, which are carried to the next draining lymph node.
• From Coeliac LNs, further permeation can occur in three directions:
  • Along lymphatics accompanying the thoracic duct to enlarged left supraclavicular glands (Vircohow's glands, or Troisier sign).
  • Along lymphatics accompanying the hepatic artery compressing the CBD, Obstructive jaundice or Portal vein causing Portal HTN and the IVC causing edema.
  • Retrograde lymphatic spread leading to enlargement of PA LNs.

Spread: Transperitoneal

• Results in malignant ascites.
• Multiple nodules on the omentum, parietal peritoneum, and surface of abdominal organs.
• In females, cells may implant on ovaries, leading to Krukenberg's tumor.
• The Rectal shelf of blumer occurs due to invasion of Douglas pouch or rectovesical pouch.

TNM Staging

• T (Tumor):
  • Tx: Primary tumor cannot be assessed.
  • T0: No evidence of primary tumor.
  • Tis: Carcinoma in situ (no invasion of the lamina propria).
  • T1: Tumor invades lamina propria, muscularis mucosae, or submucosa. T1a invades lamina propria or muscularis mucosae and T1b invades submucosa.
  • T2: Tumor invades muscularis propria (PM).
  • T3: Tumor penetrates subserosal connective tissue without invading the visceral peritoneum.
  • T4: Tumor invades serosa or adjacent structures. T4a is tumor invades serosa and T4b is tumor invading adjacent structures.
• N (Nodes):
  • Nx: Regional lymph nodes cannot be assessed.
  • N0: No regional lymph node metastasis.
  • N1: Metastasis in 1-2 regional lymph nodes.
  • N2: Metastasis in 3-6 regional lymph nodes.
  • N3: Metastasis in 7 or more, N3a is 7-15 regional lymph nodes, N3b is 16 or more regional lymph nodes.
• M (Metastases):
  • M0: No distant metastasis.
  • M1: Distant metastasis.

Presentation

• Malignant dyspepsia includes gradual onset, progressive course, and short duration and is characterized by continuous pain with no periodicity, unrelated to meals, unrelieved by drugs, unrelieved by vomiting, and weight loss
• Anemia, Anorexia, Asthenia.
• Lump, about 30% of the time signifies an incurable, non-resectable tumor.
• Ulcer-Cancer presents in older patients with a short history of dyspepsia and resists treatment.

Examination: General

• Low-grade fever, jaundice, pallor, weight loss, and hypoalbuminemia may present.
• Enlarged left supraclavicular lymph nodes (Troisier sign).
• Phelpothrombosis of superficial veins of legs (Trousseau's sign).
• Sister Mary-Josef node.

Examination: Abdominal

• A hard, irregular, epigastric mass that is mobile early on but becomes fixed and tender.
• Hepatomegaly and ascites.
• Nodules may be found in Douglas' pouch or Krukenberg's tumor

Investigations: Laboratory

• Complete blood count shows iron deficiency anemia and hypoalbuminemia.
• Tumor markers such as CA72-4, CA 19-9, and CEA.
• Occult blood in stool is positive.
• Gastric function tests reveal achlorhydria or hypochlorohydria.

Investigations:Radiology

• Double-contrast barium/gastrograffin meal can be used:
  • Fungating tumors present as an irregular-filling defect in the fundus or body of the stomach.
  • Ulcerative tumors present with a large ulcer niche outside the ulcer-bearing area, along with Carman's meniscus sign.
  • Infiltrative tumors, irregular pyloric canal.
  • Linitis plastica is the only diagnostic tool for the infection exhibiting as a narrowed, rigid stomach (Leather bottle stomach).
• Endoluminal endoscopic US is best for assessing wall penetration (T stage).
• CT and MRI.
• Positron Emission Tomography (PET).
• Gastroscopy with multiple biopsy and brush cytology is the most accurate; is used to test Malignant ulcers are suspected when:
  • If the area is outside the ulcer-bearing area.
  • The giant ulcer is more than 1 inch.
  • Malignant criteria include a raised, everted edge, necrotic floor, and indurated base.
  • Mucosal rugae fade away from the ulcer.
  • Biopsy is conclusive, cytology or punch biopsy
• Staging Laparoscopy.

Complications

• Bleeding presenting as hematemesis or melena.
• Perforation.
• Obstruction:
  • Cardia causing dysphagia.
  • Pylorus causing symptoms of gastric outlet obstruction.
• Cancer cachexia and weight loss.
• Distant metastasis.

Differential Diagnosis

• Dyspepsia: Differentiate from other causes of dyspepsia.
• Mass: Differentiate from other causes of epigastric mass.
• Ulcer: Differentiate from chronic gastric ulcer.
• Obstruction:
  • At the cardia: Differentiate from other causes of dysphagia.
  • At the pylorus: Differentiate from other causes of pyloric stenosis.
• In terms of benign vs malignant ulcers:
  • Benign ulcers are inside the ulcer bearing are while Malignant Ulcers are outside the ulcer bearing area.
  • Benign is between 1-2 cms and less than 1 inch while malignant is greater than 1 inch
  • Benign ulcers are a regular oval and rounded shape whereas ,alignant ulcers are irregular.
  • The edge of benign ulcers are sloping while malignant are everted
  • Base in benign ulcers is outside gastric contour, whereas base in malignant ulcers lies inside gastric contours
  • Mucosal old is converging in benign ulcers, and diverging in malignantly
  • The carmann meniscus sign is negative in benign, but positive in malignany

Prognosis

• Bad prognosis is indicated by:
  • Early spread, especially via lymphatics, and late presentation.
  • A low 5-year survival rate (5%).
  • Improved survival in Japan due to early detection and screening programs is seen:.
• These key factors affect prognosis:
  • Pathological staging is the most important factor.
  • An older patient has a poor prognosis.
  • A distal site is better than a proximal or total stomach.
  • Intestinal histology is better than diffuse histology.

Treatment: Operable

• Neoadjuvant chemotherapy is preferred for downstaging.
• Radical surgery is performed for early gastric cancer
• Tumor is removed with :
  • Safety margin at least 5 cm above and 1.5 cm below the duodenum.
  • Both omenta removed
  • All draining L.Ns removed
• The type of resection depends on the site of the neoplasm.
  • Lower Third (Pylorus): requires radical partial/subtotal gastrectomy with gastro-jejunal anastomosis (Billroth II, or Polya).
  • Middle Third (Body / linitis plastica) requires total radical gastrectomy with esophageal anastomosis with the jejunum.
  • Upper third requires Esophageogastrectomy with esophageal anastomosed with jejunum.
  • Spleen and/or the tail of the pancreas are excised if infiltrated

Treatment: Non-Operable

• Conditions include being an unfit patient, metastatic, and/or irresectable Pv, aorta.
• If resectable the first treatment is palliative gastrectomy
• If its located to the pyloric region and it is irresectable, palliative gastrojejunostomy takes place
• If it is in the upper region and irresectable, palliative esophageogastrectomy, or stent tube and a feeding gastrostomy may be performed.
• Other treatments are chemotherapy or radiotherapy
• Use a feeding jejunostomy to improve nourishment

Questions

• Enumerate 4 risk factors for gastric cancer?
• Enumerate 4 possible clinical presentations of gastric cancers?
• Enumerate 4 investigations for bleeding peptic ulcer?
• Why prognosis of gastric cancer is bad?
• The cause of improvement of survival in gastric carcinoma in Japan?