Surgical Pathology of the Stomach PDF

SURGICAL PATHOLOGY OF THE STOMACH Prof. Dr. Dorel Firescu Introduction to surgical anatomy stomach = dilated portion of the digestive tract; continues the esophagus and continues with the duodenum; is in the gastric box in the suprameocolic floor;  gastric lojeje demarcatio...

SURGICAL PATHOLOGY OF THE STOMACH Prof. Dr. Dorel Firescu Introduction to surgical anatomy stomach = dilated portion of the digestive tract; continues the esophagus and continues with the duodenum; is in the gastric box in the suprameocolic floor;  gastric lojeje demarcation: ♦ upper, posterior, and lateral wall - the diaphragm; ♦ anterior wall - anterior abdominal wall; ♦ lower wall - colon and transverse mesocolon; ♦ medial communicates widely with the hepatic lodge;  Projection on the anterior abdominal wall: ♦ cranial - intercostal V space; ♦ caudal - horizontal passing through the umbilicus; ♦ medial - the medioagital plane; ♦ lateral - vertical extending tangent to the left chest wall;  is shaped like a capital "J"; has a longer vertical section and a shorter horizontal section; has two walls: anterior and posterior;  two edges: ♦ straight edge = small curvature with a portion: ▫ vertical ▫ one horizontal ▫ joined by angular incision ♦ left edge = great curvature; ▫ starts from the angle it makes with the esophagus = His angle; ▫ outlines the gastric fornix; ▫ extends to the duodeno-pyloric incision;  has two sph sphincters: ♦ cardia - at the junction with the esophagus; ♦ pylorus - divides the stomach from the duodenum;  the stomach is subdivided into: ♦ gastric fundus or fornix ▫ bounded by the horizontal through the angle His; ♦ gastric body ▫ bounded at the bottom by the horizontal line passing through the angular incision; ♦ pyloric antrum and pyloric duct ▫ imprecisely demarcated by the pyloric incision; The stomach is made up of four layers: serous tunic made up of peritoneum; gives rise to the following ligamentous formations: ▫ gastrohepatic omentum; ▫ gastro-colic; ▫ gastro-splenic; ▫ gastro-pancreatic; ▫ brake-gastric;  muscular tunic longitudinal - surface fibers; circular fibers - in the middle; oblique fibers - deep; the Auerbach nerve plexus is also located here;  submucous tunic contains: ▫ vase; ▫ Meissner nerve plexus;  mucous tunic shows on its surface: ▫ Cardial glands - secrete mucus; ▫ principal and fundic glands - secrete pepsinogen and HCL ; ▫ antropyloric glands with endocrine function - gastrin; Stomach vascularization Stomach arteries originate from the celiac trunk: ♦ left gastric artery = coronary artery of the stomach; ▫ travels through the gastro- pancreatic ligament to the cardia; ▫ then moves to the small gastric curvature; ♦ common hepatic artery gives rise: pyloric artery = right gastric artery ▫ lying anterior to the pylorus; ▫ is directed toward the small gastric curvature;  gastroduodenal artery which: ▫ going posterior to the pillars, ▫ ▫ from which it is derived: ▪ right gastroepileal artery - vascularizes the great gastric curvature through the gastrocolic ligament; ♦ The splenic artery arising from the celiac trunk gives rise: left gatroepiloic artery ▫ through the gastrosplenic ligament reaches the great curvature in the gastrocolic ligament; short gastric arteries; ♦ right and left diaphragmatic arteries arising from the aortic artery. Stomach veins arise from the capillaries of the arterial network shown above; run backwards through the stomach wall; form venous plexuses: ♦ between the glandular fundus and the mucosal muscle; ♦ in the submucosa; from here they follow the arteries; carry blood into the portal vein; Limpaticele forms in the mucosa; give rise to a first subglandular plexus; run through the mucosa; second plexus - at the level of the submucosa; third plexus - at the level of the tunica muscularis;  they drain into the subserosal plexus from here the lymph is led through the larger lymph vessels to: ▫ Regional lymph nodes; ▫ in the thoracic duct;  there are four gastric lymphatic drainage zones: ♦ zone I ▪ comprises the upper region of the small curves; ▪ drains into lymph nodes around the left gastric artery; ♦ zone II ▪ distal-antral region of the small curvature; ▪ drains into the suprapyloric nodes; ♦ zone III ▪ includes the proximal portion of the great curvature; ▪ drains into the nodes around the left gastro-epiploic artery; ♦ zone IV ▪ includes the antral region of the great curvature; ▪ drains into the right gastroepiploic and subpyloric lymph nodes;  16 lymphatic stations surrounding the stomach are recognized (Japanese Research Society for the Study of Gastric Cancer); are numbered from 1 to 16: ♦ 1, 3 and 5- on small curvature; ♦ 2, 4 and 6 on the great curvature; ♦ 7 on the left gastric artery;  ♦ 8 on common hepatic areta; ♦ 9 on celiac trunci; ♦ 10 and 11 on splenic artery; ♦ from 12->16 mesenterial and aortico- caval ganglionic groups; lymph node stations have been systematized into three compartments; are successively co-involved in neoplastic metastasis: ♦ Compartment I ▫ the large and small gastric ganglia of the gastric curvature (stations 1-6); ♦ Compartment II ▫ nodes of the celiac trunk, hepatic pedicle, splenic artery (stations 7 - 11); ♦ compartment III ▫ para-aortic and mesenterial lymph nodes (stations 12-16 ); gastric lymph anastomoses:  lymphatics of the proximal stomach with those of the distal esophagus;  the lymphatics of the stomach and duodenum - less numerous; Stomach nerves come from the vegetative nervous system; ♦ parasympathetic (vagus nerve); ♦ sympathetic (celiac plexus); Stomach physiology Motor function ♦ is different: in the proximal stomach (fornix and proximal body segment) ▪ motor activity is tonic; ▪ receptive relaxation character =►►reservoir function; in the distal stomach = "anthropic pump" ▪ seat of rhythmic peristaltic waves; ▪ mix, grind and propel food; ▪ the coordination center of this activity is:  in the vertical segment of the great curvature;  in a cluster of myenteric cells (pacemaker);  Secretarial function ♦ is different: exocrine secretion ▪ is the fruit of the secretion of the gastric mucosa; ▪ gastric fluid results: - colorless or slightly opalescent; - pH acid 0.8 - 1.5; - about 1.5 - 3 l/24 hours;  ▪ contains: - hydrochloric acid ▫ originate in parietal or oxyntic cells; ▫ glands of the fundic region and gastric body; ▪ basal or resting secretion is 2-5 mEq/h HCl; ▪ stimulated secretion =► values between 22 - 25 mEq/h HCl; - ferments: - pepsin: - secreted:  of main cells  in the form of pepsinogen - lipaza;  - gastric mucus; ▫ secreted by the lining epithelium; ▫ mucoid cells of the pyloric glands; ▫ cardiac glands; ▫ forms a 1 - 1.5 mm thick layer; ▫ to protect against aggression: ▪ mechanical; ▪ thermal; ▪ Chemical; ▪ chlorhydropeptic autodigestion; - intrinsic factor ▫ interferes with the absorption of vitamin B12 from food;  endocrine secretion mainly represented by: - gastrin ▪ produced in the antral region ▪ with role in: ▫ stimulation of chlorhydropic secretion; ▫ stimulating gastric motility; ▫ trophic role of body mucosa and gastric fornices; - somatostatin ▪ secreted in: -stomach; -pancreas; -intestin; ▪ plays a role in regulating acid secretion and gastrin release;  Paraclinical investigations in gastrointestinal lesions Radiologic examination: makes the diagnosis in 80% of cases; cannot highlight superficial lesions; it hardly highlights lower esophageal ulcer; there are two types of signs:  3.gastric antrum;12 pylorus;6 bulb;5.DII ► direct signs represented by the niche = retention of barite substance at the level of the ulceration; seen in profile outside the gastric contour in several shapes: ▫ small triangular niche; ▫ medium-sized niche; ▫ pediculate niche (pseudodiverticulum of the small curvature);  ▫ three-level Haudec niche: - barium; - liquid; - air; ▫ giant niche over 5 cm; in the present incidence it realizes the appearance of the niche in the ‫״‬coccardial‫;״‬ ►indirect sign less relevant in gastric ulcer; to the right of the lesion located on the lesser curvature => spastic incision of the greater curvature = finger pointing ulcer; convergence of gastric mucosal folds to ulcer; the look of a strand;!!!!! deformation of the bulb - in duodenal ulcer; ► can differentiate between: gastric ulcer - ulcerated gastric tumor;  Gastric endoscopy modern exam; complete the radiologic examination; allows biopsy; shows the lesion in 97% of cases;  Study of gastric secretion more important in duodenal than gastric ulcers; Helicobacterpylori infection Helicobacterpylori = spiral gram (-) bacillus; recognized as a major cause of ulcer disease; is also a risk factor for malignant gastric lesion;  associated with: ▪ atrophic gastritis; ▪ gastric ulcer; ▪ duodenal ulcer; ▪ gastric cancer; is present in 90% of patients with duodenal ulcer;  antimicrobial therapy =" a higher percentage of cures than with H2 receptor antagonists; is eradicated by treatment with bismuth; patients treated with bismuth have a lower rate of disease relapse; Helicobacter infection - contracted in childhood, from water and food;  persists for life if left untreated; the presence of the bacillus is detected by: ♦ identification on tissue from gastric mucosal biopsy by: ▫ Giemsa coloring; ▫ culture from biopsy material;  ♦ urease test; ♦ serologic test (IgG antibodies); ♦ DNA identification from saliva or stool; SURGICAL PATHOLOGY OF THE STOMACH Prof. Dr. Dorel Firescu  Gastric ulcer Etiopathogenesis contour acidopeptic hypersecretion < than in duodenal ulcer; decreased gastric mucosal defenses; gastric motility disorders; duodenogastric reflux =" chronic reflux gastritis;  Reducing defense factors Preepithelial barrier = Mucus + Bicarbonate -opposes H+ backscattering -synthesis of mucus e(+) of PGE2 Epithelial barrier - the integrity of the apical membrane and ileo-cecal junction. Post-epithelial barrier - vascularization of the muc. ensures – nutrient intake – bicarbonate intake – backscattered H+ uptake Factors involved in mucosal protection – Prostaglandins – mucus, bicarbonate strengthen the epithelial barrier – o(+) microcirculation Epidermal growth factor (EGF) Other growth factors - Nitric oxide -> (+) mucus, improves circulation  Helicobacter Pylori infection - more important in duodenal ulcer; exogenous factors: ▪ anti-inflammatory drugs; ▪ chemotherapy treatment; ▪ smoking; ▪ alcohol; Pathologic anatomy ► Acute ulcer with two variants: ♦ gastric erosion = exulceratio simplex does not exceed muscularis mucosae; common cause of acute hemorrhagic gastritis; ♦ deep acute ulcer involves almost all layers of the gastric wall; has a diameter of about 1 cm; is surrounded by edema and hyperemia; heals into a visible scar; it complicates generating: ▪ hemorrhage; ▪ perforation; ►Chronic ulcer are Ø >2-5 cm; is surrounded by a chronic inflammatory process;  Johnson classification by location type 1 = small curvature ulcer: - reduced acid secretion compared to normal; - accompanied by: ▪ gastritis; ▪ duodenal reflux; - more often blood group A;  type 2 - located on the small curvature in the gastric body and associated with pyloric or duodenal ulcer even stenosing; - increased HCl level; - is considered secondary to doudenal ulcer (pathogenic); - more common in blood group 0;  type 3 - with antral, prepyloric localization - behaves symptomatically and secretory similar to duodenal ulcer; - still blood type 0; - has acid hypersecretion; - Kauffman and Conter add two more types of gastric ulcer: type 4 - on the small high curvature near the gastroesophageal junction; type 5 - different localization: - result of chronic aspirin or anti- inflammatory drug ingestion; Clinical diagnosis Pain: ♦ localization epigastric or retrosternal or left paramedian or right in the left hypochondrium; it depends on the location of the ulcer in the stomach; ♦ character of: burn; throbbing; ♦ caused by food intolerance; appear early postprandial; ♦ soothed by: evacuation of food from the stomach into the duodenum; vomiting; less after taking alkaline medicines;  Vomiting and nausea ♦ more common in high gastric ulcer sites; ♦ no constant symptoms; Pirozisul ♦ early postprandial onset is more likely a sign of an association: high located ulcer + hiatal hernia; ♦ symptom characteristics : less distinct periodicity than in duodenal ulcer; in acute forms sometimes spontaneously subsides after 1-4 weeks; in chronic ulcer symptomatology: - returns for long periods; - sometimes associated with transfixing pain = pain in the bar suggesting penetrating character; Paraclinic Radiologic examination useful in 80% of cases; direct signs = niche with multiple aspects: - triangular shape; - pseudodiverticular form; - Haudec niche with three levels (air, secretion liquid, barium); - the niche in the cockpit (the image of a niche);  indirect signs can be represented by: - shortening of the small gastric curves; - spastic incision at the level of the greater curvature, opposite the ulcer located on the lesser curvature (the finger pointing to the ulcer); - convergence of folds, e.t.c.;  Gastric endoscopy complements radiologic exploration; allows: - visualization of the lesion; - biopsy;  Gastric secretion less important as a method; is more useful for differentiating benign from malignant lesions; the latter being associated with hypo- or histamine-resistant anaciditis; Helicobacter pylori infection is always present; Developments Burdened by complications which in order of frequency are: ▫hemorrhagia - more abundant than in duodenal ulcers; - with reduced tendency to spontaneous arrest; - with relatively high mortality; ▫ perforation - the most common complication of ulcers sitting on: - small curve; - the anterior front of the stomach; ▫ stenosis - complicates prepyloric ulcers; - causes symptoms identical to pyloric stenosis in duodenal ulcer; - can complicate the ulcer of the small gastric curves in the vicinity of the gastric angle =" medio-gastric stenosis; - gives the radiologic appearance of an hourglass stomach; ▫ penetration - occurs in old, chronic ulcers; - is specific to posteriorly located ulerechia; - can be in: - pancreas; - transverse colon; ▫ malignization any chronic gastric ulcer should be suspected of malignant lesion; requires endoscopic biopsy; Clinical forms of gastric ulcer Subcardial ulcer (Johnson I) ♦ has symptoms of low esophageal lesion with: ▪ dysphagia; ▪ regurgitation; ▪ early postprandial pain;  Prepyloric ulcer (Johnson III) ▪ is much more painful; ▪ it takes on the characters of duodenal ulcer symptoms: ▫ epigastric pain; ▫ late postprandial onset; ▫ low and high periodicity;  Stress ulcers ♦ found in : politrumatism; widespread burns (over 35% of the surface area = curling ulcer); renal failure oliguric form; major surgery; brain damage (Cushing's ulcer), e.t.c.; ♦ is oligosymptomatic; ♦ its most common manifestation is painless upper gastrointestinal bleeding; ♦ is usually superficial; ♦ cannot be revealed by radiologic examination; ♦ The endoscopic examination is the examination of choice in making this diagnosis; Treatment Medical treatment ♦ is done under rigorous and periodic radiologic and/or endoscopic control; ♦ for six (6) weeks the ulcerative lesion must reduce in volume to less than 60% of its original diameter; ♦ otherwise the lesion is labeled as: ▪ resistant to drug treatment; ▪ either as a neoplastic lesion; ▪ requires surgery; ♦ is administered: antacids e.g. - H2 receptor antagonists: ▪ omeprazole; ▪ pantoprazole; ▪ Against;  substances that stimulate gastric mucosal defenses: ▪ anticholinergics; ▪ misoprostol = analog of prostaglandin PgE1; ▪ carbenoxolone;  anti-infective treatment for Helicobacter pylori: ▪ tetracycline; ▪ amoxicillin; ▪ clarithromycin; ▪ metronidazole; ▪ colloidal bismuth (De-Nol); Ex: Bismuth 480mg/day +clarithromycin 500mg + tetracycline 200mg hygienic-dietary regimen with avoidance: ▪ coffee; ▪ alcohol; ▪ anti-inflammatory drugs such as aspirin;  Surgical treatment indicated when medical treatment for six weeks has failed; when a malignant lesion is suspected; in complications of gastric ulcer; consists of gastric resection, with removal of the ulcerative lesion;  depending on the location of the lesion can be: - hemigastrectomy with gastroduodenosis or jejunoanastomosis; - saddle gastric resection = scalariform gastric resection with gastroduodenosis or gastrojejunostomy anastomosis; - mediogastric resection with gastro- gastro-anastomosis, associated vagotomy with pyloroplasty; - upper polar gastric resection in the case of an ulcer located at the junction with the esophagus;  BENIGN TUMORS are relatively rare; originate in various tissues: – epithelial, – mezenchimale; more common towards the second half of life;  account for 5-7% of all gastric tumors; 40% of cases = polyps; and another 40% = tumors of muscular origin; Etiopathogenesis etiopathogenesis is not elucidated; factors are invoked:  genetic;  family;  chronic mucosal inflammation;  irritating diet;  anemia (especially Biermer);  smoking;  excessive alcohol and coffee consumption;  Classification according to their origin are classified into: epithelial: ▪ adenomatous polyps; ▪ hyperplastic polyps;  mezenchimale: ▪ leiomyomas; ▪ fibromiomyomas; ▪ lipoam; ▪ neurogenic tumors; ▪ vascular tumors; ▪ osteoma; ▪ osteochondromas;  miscellaneous: ▪ inflammatory pseudotumors; ▪ heterotopic pancreatic tumors; ▪ hamartoame; ▪ cystic tumors;  by number: single; multiple; relative to the implant base: pediculate; sesile; Pathological anatomy Macroscopically, lesions can be: ♦ single or multiple; ♦ sessile or pedicate; ♦ circumscribed or diffuse; ♦ ulcerated or not; ♦ in most cases being localized: in the lower gastric pole; on the body of the stomach; more rarely on the fornix; Microscopically, the structure of tumors is similar to the tissue of origin. Clinic Symptomatology of benign gastric tumors is deleted uncharacteristic, asymptomatic until complications develop: occult bleeding ± secondary anemia; macroscopically evident gastrointestinal hemorrhages - following tumor ulceration;  postprandial abdominal discomfort; intermittent, intractable vomiting due to obstruction of the pylorus in pedunculated antropyloric antropyloric tumors;  The objective examination provides incomplete data. inspection =" bulging of the epigastrium; palpation: epigastric impingement; the presence of an epigastric tumor; percussion matitate in large tumors;  general condition remains unchanged for a long time; sometimes described: weight loss; anemia; asthenia; Paraclinical explorations ♦ Contrast-enhanced gastro-duodenal radioscopy: is useful in tumors larger than 1 cm in diameter; highlights the gaps; ♦ Fibrogastroscopy the elective exam: provides data on: localization; number; volume; their macroscopic appearance; allows for HP sampling and even excision ♦ Gastric chemosis shows hypoacidity or anaciditis in over 75% of cases; gastric juice can be made: ♦ Cytologic examinations that: from gastric aspirate sediment It guides the diagnosis to benign or malignant; Treatment is depending on:  tumor size;  macroscopic appearance;  complications;  treatment can be: endoscopic ± follow-up at variable intervals; surgical: ▪ strictly limited to the tumor; ▪ extensive resections;  MALIGNANT TUMORS ♦ origin: epithelial = cancers mezenchimala = sarcomas GASTRIC SARCOMAS ♦ of Mezenchimala origin; ♦ have a frequency of 1-3% of all stomach tumors;  Classification ♦ by the origin of the tissue from which they come: malignant lymphoma: ▪ primitive (non-Hodgkin's); ▪ secondary - originating in lymphoid and reticular cells; leiomyosarcomas with starting point: ▪ in the smooth muscle of the stomach; ▪ in muscularis mucosae;  fibrosarcoma: ▪ develops from fibrous tissue with few cellular elements; angiosarcoma: ▪ come from elements of vascular tissue; neurosarcomas- although ectodermal in origin;  MALIGNANT LYMPHOMA ♦ represents: 4.5% of gastric neoplasms; 60% of stomach sarcomas; ♦ may manifest as -primary tumors -secretion of general lymphatic diseases (Hodgkin's) Etiopathogenesis Their etiopathogenesis not known; H. pylori associated with lymphoid tissue is thought to favor the development of primary B-cell lymphomas with a low degree of differentiation;  the eradication of H. pylori caused tumor involution; the disease appears around the age of 56; limits between 28-78 years; more common in men (1.7/1);  is considered primary malignant gastric lymphoma if the patient: - no superficial adenopathy; - no widened mediastinal image due to denopathy; - the lymphocyte count ă is within normal limits; - no splenomegaly or hepatomegaly. Pathologic anatomy Macroscopically, maningeal lymphomas take several forms: - infiltrative; - ulcerative; - nodulara; - polypoid; - combinations of the above forms; Microscopic well differentiated; poor differentiation; mixed-cell; histiocytic type; undifferentiated, Clinic ♦ is similar to gastric cancer; ♦ from which it differs with difficulty; ♦ Described: epigastric pain (80%) ≈ gastric ulcer: intense, decreased by ingestion of food and antacids; anorexia; nausea;  vomiting; Dysphagia - in cardio-tuberozitaritar localozarile; externalized bleeding in the form of: hidden losses (about 50%); hematemesis and melena; perforations in the large cavity; penetrations into neighboring organs; ♦ Objective examination finds: presence of epigastric tumors (50%) difficult to delineate and painless; Weight loss is frequent and early, as in gastric cancer; hepatomegaly and splenomegaly are present; Paraclinical explorations ♦Burned barite infiltrative appearance similar to plastic lymphitis; ♦ Endoscopy looks: thickening of gastric folds and mucosal ulcerations; biopsy should be done deeply from the submucosa; is the only one that specifies the diagnosis; ♦ Echoendoscopy reveals thickening of the gastric wall and the presence of nodular formations; ♦ Laboratory tests reveal: anemia; presence of occult bleeding; gastric anaciditis; Treatment In the primary one: ♦ is complex; ♦ is made in relation to the evolutionary stage; ♦ it is much more effective than for carcinomas; Secondary ones: ♦ follows treatment of systemic disease; Surgical treatment ♦ is essential; ♦ all patients with suspected lymphoma should be laparotomized for: diagnosis; the assessment of resectability reaching 57-60%;  In relation to the extension of the tumor and lymph node involvement can be practiced: – wide gastric resections; – Locoregional lymph node highlighting; – splenectomy; – in the case of invasion of neighboring viscera =" as far as possible, their extirpation; Radiotherapy postoperative in doses of 30-40 Gy is indicated in all cases; is contraindicated: ▪ in patients with altered general condition; ▪ in case of necrosis of an ulcerated tumor; ▪ in cases at risk of fistularization; Chemotherapy is indicated in: systemic localizations; in case of lymph node invasion;  LEIOMIOSARCOMUL ♦ accounts for 1% of all malignant tumors; ♦ 30-40% of mesenchymal malignant tumors; Pathological anatomy Macroscopic: - resembles leiomyoma; - with mucosal ulcerations; - with hemorrhagic foci and areas of necrosis; - being localized, in 75% of the cases, in the body-fundal area; ♦ the tumor is: sesila or pediculata; 5-20 cm in diameter; has endo- or exogastric evolution invade: gastric wall; the great and little epiploon; Clinic Symptomatology is represented by: - digestive bleeding; - epigastric pain; - weight loss; The objective examination reveals: palpation of an epigastric tumor mass, difficult to delineate, painless; - signs of generalized or localized peritonitis due to tumor perforation; Paraclinical explorations The churned transit Endoscopy : presence of submucous tumor; mucosal ulcerations; the diagnosis is specified by:  deep biopsies,  multiple; Treatment The basic treatment is surgical: consists of wide gastrectomies for distal localizations; in total gastrectomies with abdominal esophagectomies, in cardio-tuberous localizations; Postoperative chemotherapy is indicated in case of: ▪ leiomyomas; ▪ rhabdomyosarcomas; Radiotherapy no results;  HIGH SARCOAME ♦ much rarer in frequency:  Fibrosarcomul  Fibroliposarcoma  Hemangiopericytoma  Kaposi's sarcoma  Malignant schwannoma (neurofibrosarcoma)  GASTRIC CANCER is the most common malignant tumor of the stomach; developed from the epithelium of the gastric mucosa or glands; Epidemiology gastric cancer has an uneven distribution across the globe; There are areas with high lesion frequency (Japan, China, Russia, etc.) and areas with low lesion frequency (USA, Sweden, France, Poland, Romania, etc.);  Gastric cancer occupies: - 6th place in cancers overall; - 3rd place in digestive tract cancers; The average age affected is 60 (50- 70); the sex most commonly affected is male (B/F = 2/1); Etiopathogenesis The causes of this condition are not known. Several factors are thought to be involved, such as : - genetic factors - family factors play an important role; - infectious factors - Helicobacter Pylori infection is discussed; - predisposing gastric conditions - atrophic gastritis; - gastric ulcer; - gastric polyposis; - gastric mucosal dysplasia; - Menetrier's hypertrophic gastritis; - dietary factors - there are: - food factors that protect the gastric mucosa (milk, vegetables, fruit, cold preserved foods); - dietary factors that favor the development of the lesion (coffee, alcohol, smoked foods, nitrosamines, etc.); - working conditions - professions that predispose to this injury: printers, painters, miners, e.t.c. Pathologic anatomy Macroscopic - they are shapes: - vegetarian; - ulcerate; - infiltrative (plastic lymphitis); - mixed;  Incipient cancer = "early cancer" = tumor detected in the early stage limited to mucosa and submucosa. The following forms are described: type I - protruding; type II - superficial with three forms: - high; - flat; - uneven; type III - ulcerated = excavated - similar to a benign ulcer;  Microscopically there are two forms: adenocarcinoma: -papillary, -tubular, -coloid, -with cells in ‫ ״‬seal ring‫;״‬ carcinoam: -we nod, -epidermoid, -undifferentiated, -small-cell; The extent of gastric cancer through the gastric wall - axial and longitudinal; lymphatic - of choice is done in the regional lymph nodes. There are 4 gastric lymphatic drainage zones: - zone I - nodes around the left gastric artery; - zone II - suprapyloric ganglia; - zone III - lymph nodes around the left gastroepiglossal artery; - zone IV - the right gastroepileal and subpyloric ganglia;  The Virchow Troisier supraclavicular lymph nodes are added; blood - venous, causing liver, lung, adrenal, bone metastases; peritoneal dissemination causes peritoneal carcinomatosis and/or Kruckenberg's ovarian tumor; Gastric cancer staging There are several classifications:  Dukes (as in colon);  Astler-Coller; The most commonly used and accepted in our country is the UICC staging which uses the TNM system in which T starts from Tis, T1 -T4, N has 5 categories and results in 4 stages;  T - primary tumor Tx - the primary tumor cannot be appreciated; T0 - no primary tumor; Tis- (carcinoma in situ) - intraepithelial tumor without invasion of the lamina propria; T1 - tumor invading the lamina propria or submucosa; T2 - a tumor invading the muscularis propria or subserosus, without invasion of surrounding organs; T3 - tumor that exceeds the serosa but without invasion of adjacent organs; T4 - invades adjacent viscera;  N - regional lymph nodes Nx - regional nodules cannot be assessed; N0 - no regional lymph node metastases; N1 - metastases in 1-6 regional lymph nodes; N2 - metastases in 7-15 regional lymph nodes; N3 - metastases in more than 15 regional lymph nodes.  M - distant metastases: Mx - a can be evaluated; M0 - no distant metastases; M1 - presence of distant metastases.  TNM staging Stage O Tis N0 M0 Stage IA T1 T1 N0 M0 Stage IB T1 T1 N1 M0 T2 N0 M0 Stage II T1 N2 M0 T2 N1 M0 T3 N0 M0 Stage IIIA T2 T2 N2 M0 T3 N1 M0 Stage IIIB T3 N2 M0 T4 N1 M0 Stage IV T4 N2 M0 T N M1  The histologic grade of the tumor is also important: Gx - cannot be specified; G1 - well differentiated; G2 - moderately differentiated; G3 - poorly differentiated; G4 - undifferentiated; Clinic In the early days: unsystemized dyspeptic syndrome; anorexia; flatulence; early postprandial satiety; In the state period: decreased appetite; selective meat anorexia; epigastric pain that responds to treatment; vomiting Hematemesis and melena; dysphagia in esogastric junction cancers; General signs: - on debut are deleted; - only present during the state period:.asthenia,.weight loss,.pallor ‫(״‬like straw‫;)״‬ Objective examination - can highlight: - epigastric tumor on palpation; - epigastric and periumbilical impingement, - Virchow-Troisier left supraclavicular adenopathy; - ascites; - migratory phlebitis, e.t.c. Paraclinic Radiologic examination with contrast: - is basic exploration; - can show: - lacunar image->plant forms - out-of-contour niche in ulcerated forms; - the appearance of the wave plank in infiltrative forms, which cancel peristalsis in the area concerned. Endoscopy - is the best test for diagnosing this lesion; - can even detect early cancers; - allows the taking of fragments for histopathologic examination; Ultrasound - only of value in advanced forms; Echoendoscopy - can assess both the superficial extent of the tumor as well as its depth. Tomocomputer is useful but not indispensable highlighting: - thickening of the gastric wall; - extension in neighboring geographies; - liver metastases; Tumor markers are: - immunological; - tumor - having a more important prognostic role and being represented by:  carcinoembryonic antigen;  carbohydrate antigen;  tissue polypeptide antigen; Clinical forms Quote: Anthropogenic cancer - as the most common localization; Cardio-Tuberous Heart Cancer; plastic lymphitis or gastric cirrhosis;  According to the symptoms are described: - anemic form; - pseudoulcer form; - febrile form; - the cachectic form; Evolution and complications: Progress without treatment - about 6-24 months until the onset of complications that can be: - bleeding; - pyloric stenosis; - perforation; - migratory phlebitis; - metastases; Treatment It is mainly : surgical can be oncology-targeted, which involves removing : - the great epiplon; - of the tumor lesion within safe oncological limits; - drainage nodes; palliative surgical treatment - only to improve quality of life;  Depending on the location of the tumor, resections can be: - subtotal; - total; - associating or not, depending on localization:. caudal esophagectomy,. splenectomy,. duodenectomy;  Adjuvant treatments can also be used: - radiotherapy, with poor results; - Chemotherapy-seems to be gaining ground:.in mono or poly chemotherapeutic form,.by the general or local intraperitoneal route,